- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,235.71 / $2,533.80 / $3,251.94
| Facility | | $2,235.71 | $2,533.80 | $3,251.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.94 / $3,251.94 / $3,251.94
| Professional | | $3,251.94 | $3,251.94 | $3,251.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.88 / $2,837.64 / $3,387.44
| Professional | | $2,553.88 | $2,837.64 | $3,387.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.95 / $3,251.94 / $3,793.93
| Professional | | $2,980.95 | $3,251.94 | $3,793.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.95 / $3,251.94 / $4,064.93
| Professional | | $2,709.95 | $3,251.94 | $4,064.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.46 / $3,658.43 / $6,097.39
| Professional | | $2,303.46 | $3,658.43 | $6,097.39 |