- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $8,511.38
| Facility | | $2,818.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,344.23
| Professional | | $1,348.96 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,041.74
| Professional | | $1,584.89 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $2,884.03
| Professional | | $2,187.76 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,778.28 / $2,238.72
| Professional | | $1,621.81 | $1,778.28 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $2,570.40
| Professional | | $1,659.59 | $1,905.46 | $2,570.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $11,220.18
| Professional | | $1,949.84 | $5,623.41 | $11,220.18 |