- 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
- $1,023.29 / $1,584.89 / $1,698.24
| Professional | | $1,023.29 | $1,584.89 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,737.80
| Professional | | $1,513.56 | $1,513.56 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $2,511.89
| Professional | | $1,905.46 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $1,584.89
| Professional | | $1,258.93 | $1,380.38 | $1,584.89 |
- 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
- $1,230.27 / $1,584.89 / $2,041.74
| Professional | | $1,230.27 | $1,584.89 | $2,041.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,548.82 / $1,949.84
| Professional | | $29.51 | $1,548.82 | $1,949.84 |