- 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
- $2,454.71 / $2,818.38 / $3,548.13
| Professional | | $2,454.71 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $3,630.78
| Professional | | $2,570.40 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,677.35
| Professional | | $3,467.37 | $3,801.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $3,801.89
| Professional | | $2,691.53 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,162.28 / $4,168.69
| Professional | | $2,089.30 | $3,162.28 | $4,168.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,630.27 / $3,548.13
| Professional | | $29.51 | $2,630.27 | $3,548.13 |