- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.23 / $2,270.23 / $2,270.23
| Facility | | $2,270.23 | $2,270.23 | $2,270.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.27 / $2,074.13 / $3,032.41
| Professional | | $1,968.27 | $2,074.13 | $3,032.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,756.74 / $2,886.64 / $3,586.77
| Professional | | $2,756.74 | $2,886.64 | $3,586.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.86 / $2,473.53 / $3,847.72
| Professional | | $1,923.86 | $2,473.53 | $3,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.33 / $2,206.78 / $3,032.41
| Professional | | $1,239.33 | $2,206.78 | $3,032.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.23 / $2,391.17 / $2,756.74
| Professional | | $2,263.23 | $2,391.17 | $2,756.74 |