- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $1,949.84
| Professional | | $1,288.25 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,513.56 / $2,041.74
| Professional | | $1,445.44 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $7,762.47
| Professional | | $1,949.84 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $2,187.76
| Professional | | $1,548.82 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,344.23
| Professional | | $1,174.90 | $1,621.81 | $2,344.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $6,165.95
| Professional | | $1,288.25 | $2,691.53 | $6,165.95 |