- 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
- $2,884.03 / $3,235.94 / $4,677.35
| Professional | | $2,884.03 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $4,466.84
| Professional | | $3,162.28 | $3,890.45 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,897.79 / $5,888.44
| Professional | | $4,466.84 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $4,466.84
| Professional | | $3,162.28 | $3,548.13 | $4,466.84 |
- 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
- $2,630.27 / $3,715.35 / $5,248.07
| Professional | | $2,630.27 | $3,715.35 | $5,248.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $3,467.37 / $4,466.84
| Professional | | $29.51 | $3,467.37 | $4,466.84 |