- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,862.09 / $2,041.74
| Professional | | $1,023.29 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,949.84
| Professional | | $1,819.70 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,818.38
| Professional | | $2,187.76 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $2,041.74
| Professional | | $1,584.89 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $2,398.83
| Professional | | $1,479.11 | $1,862.09 | $2,398.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,778.28 / $2,570.40
| Professional | | $29.51 | $1,778.28 | $2,570.40 |