- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $6,918.31
| Facility | | $2,818.38 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,089.30 / $2,630.27
| Professional | | $1,778.28 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $2,630.27
| Professional | | $1,862.09 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $3,311.31
| Professional | | $2,630.27 | $2,951.21 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,818.38
| Professional | | $1,995.26 | $2,238.72 | $2,818.38 |
- 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
- $1,513.56 / $2,187.76 / $3,019.95
| Professional | | $1,513.56 | $2,187.76 | $3,019.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,905.46 / $2,570.40
| Professional | | $29.51 | $1,905.46 | $2,570.40 |