- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.62 / $2,180.62 / $2,180.62
| Facility | | $2,180.62 | $2,180.62 | $2,180.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,890.58 / $3,019.43
| Professional | | $1,786.79 | $1,890.58 | $3,019.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.94 / $2,874.28 / $3,605.36
| Professional | | $2,744.94 | $2,874.28 | $3,605.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.46 / $2,470.44 / $3,842.92
| Professional | | $196.46 | $2,470.44 | $3,842.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.33 / $2,180.62 / $3,019.43
| Professional | | $1,254.33 | $2,180.62 | $3,019.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.73 / $2,282.38 / $2,612.67
| Professional | | $1,311.73 | $2,282.38 | $2,612.67 |