- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,821.87 / $2,821.87 / $2,821.87
| Facility | | $2,821.87 | $2,821.87 | $2,821.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $3,293.15
| Professional | | $326.16 | $2,399.94 | $3,293.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,120.89 / $4,315.08 / $5,395.35
| Professional | | $4,120.89 | $4,315.08 | $5,395.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,250.99 / $3,250.99 / $3,250.99
| Professional | | $3,250.99 | $3,250.99 | $3,250.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.34 / $2,821.87 / $3,392.70
| Professional | | $1,905.34 | $2,821.87 | $3,392.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,422.09 / $3,422.09 / $4,120.89
| Professional | | $3,422.09 | $3,422.09 | $4,120.89 |