- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $3,235.94
| Professional | | $2,089.30 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,162.28
| Professional | | $2,238.72 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,311.31 / $3,981.07
| Professional | | $3,019.95 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $3,019.95
| Professional | | $2,137.96 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $3,715.35
| Professional | | $1,862.09 | $2,754.23 | $3,715.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,041.74 / $3,890.45
| Professional | | $29.51 | $2,041.74 | $3,890.45 |