- 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
- $1,258.93 / $2,290.87 / $2,511.89
| Professional | | $1,258.93 | $2,290.87 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,454.71
| Professional | | $2,238.72 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $3,548.13
| Professional | | $2,754.23 | $3,388.44 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $2,454.71
| Professional | | $1,949.84 | $2,137.96 | $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
- $1,819.70 / $2,290.87 / $3,019.95
| Professional | | $1,819.70 | $2,290.87 | $3,019.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $2,290.87 / $2,454.71
| Professional | | $309.03 | $2,290.87 | $2,454.71 |