- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,512.51 / $3,512.51 / $3,512.51
| Facility | | $3,512.51 | $3,512.51 | $3,512.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $3,045.33 / $4,689.77
| Professional | | $2,672.64 | $3,045.33 | $4,689.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.43 / $4,464.32 / $5,547.12
| Professional | | $4,263.43 | $4,464.32 | $5,547.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.34 / $3,825.43 / $5,950.67
| Professional | | $2,975.34 | $3,825.43 | $5,950.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.25 / $3,412.13 / $4,689.77
| Professional | | $1,916.25 | $3,412.13 | $4,689.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.22 / $3,698.08 / $4,263.43
| Professional | | $3,500.22 | $3,698.08 | $4,263.43 |