- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $2,454.71
| Facility | | $1,659.59 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $1,949.84
| Professional | | $1,318.26 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,511.89
| Professional | | $2,041.74 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,454.71 / $3,019.95
| Professional | | $2,238.72 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,041.74 / $3,019.95
| Professional | | $1,023.29 | $2,041.74 | $3,019.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,951.21 / $4,570.88
| Professional | | $1,737.80 | $2,951.21 | $4,570.88 |