- 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
- $1,949.84 / $3,548.13 / $3,801.89
| Professional | | $1,949.84 | $3,548.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,715.35
| Professional | | $3,388.44 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,365.16 / $5,248.07
| Professional | | $4,073.80 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,235.94 / $3,715.35
| Professional | | $2,951.21 | $3,235.94 | $3,715.35 |
- 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
- $2,754.23 / $3,548.13 / $4,570.88
| Professional | | $2,754.23 | $3,548.13 | $4,570.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $3,548.13 / $3,981.07
| Professional | | $478.63 | $3,548.13 | $3,981.07 |