- 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 / $1,584.89 / $1,949.84
| Professional | | $1,348.96 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $1,819.70
| Professional | | $1,548.82 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $2,570.40
| Professional | | $1,949.84 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $2,187.76
| Professional | | $1,584.89 | $1,737.80 | $2,187.76 |
- 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
- $1,513.56 / $1,737.80 / $2,344.23
| Professional | | $1,513.56 | $1,737.80 | $2,344.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,445.44 / $1,995.26
| Professional | | $29.51 | $1,445.44 | $1,995.26 |