- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $2,818.38
| Facility | | $1,949.84 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $2,951.21
| Professional | | $2,344.23 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $3,467.37
| Professional | | $2,570.40 | $2,818.38 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,344.23 / $3,467.37
| Professional | | $1,174.90 | $2,344.23 | $3,467.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,467.37 / $5,248.07
| Professional | | $1,995.26 | $3,467.37 | $5,248.07 |