- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,150.74 / $4,704.17 / $6,037.44
| Facility | | $4,150.74 | $4,704.17 | $6,037.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,037.44 / $6,037.44 / $6,037.44
| Professional | | $6,037.44 | $6,037.44 | $6,037.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,268.27 / $6,289.00
| Professional | | $5,031.20 | $5,268.27 | $6,289.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,534.32 / $6,037.44 / $7,043.68
| Professional | | $5,534.32 | $6,037.44 | $7,043.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $6,037.44 / $7,546.80
| Professional | | $5,031.20 | $6,037.44 | $7,546.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,276.52 / $6,792.12 / $11,320.20
| Professional | | $4,276.52 | $6,792.12 | $11,320.20 |