- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $2,570.40
| Professional | | $1,348.96 | $1,995.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,089.30 / $2,238.72
| Professional | | $1,778.28 | $2,089.30 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $3,235.94
| Professional | | $2,454.71 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $2,454.71
| Professional | | $1,819.70 | $1,949.84 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $2,754.23
| Professional | | $1,698.24 | $2,238.72 | $2,754.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $2,137.96 / $3,162.28
| Professional | | $288.40 | $2,137.96 | $3,162.28 |