- 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
- $1,096.48 / $1,995.26 / $2,187.76
| Professional | | $1,096.48 | $1,995.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,089.30
| Professional | | $1,949.84 | $1,949.84 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $3,019.95
| Professional | | $2,344.23 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,137.96
| Professional | | $1,698.24 | $1,819.70 | $2,137.96 |
- 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
- $1,584.89 / $1,995.26 / $2,570.40
| Professional | | $1,584.89 | $1,995.26 | $2,570.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,995.26 / $2,951.21
| Professional | | $29.51 | $1,995.26 | $2,951.21 |