- 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
- $2,884.03 / $3,388.44 / $4,265.80
| Professional | | $2,884.03 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $3,890.45
| Professional | | $3,311.31 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,677.35 / $5,623.41
| Professional | | $4,265.80 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $4,677.35
| Professional | | $3,388.44 | $3,715.35 | $4,677.35 |
- 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
- $3,162.28 / $3,715.35 / $5,128.61
| Professional | | $3,162.28 | $3,715.35 | $5,128.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $3,090.30 / $4,365.16
| Professional | | $29.51 | $3,090.30 | $4,365.16 |