- 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
- $1,584.89 / $4,897.79 / $5,495.41
| Professional | | $1,584.89 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,786.30
| Professional | | $2,041.74 | $2,041.74 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $4,897.79
| Professional | | $3,715.35 | $3,981.07 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,466.84 / $5,128.61
| Professional | | $4,073.80 | $4,466.84 | $5,128.61 |
- 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
- $1,949.84 / $4,786.30 / $6,456.54
| Professional | | $1,949.84 | $4,786.30 | $6,456.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,570.40 / $5,370.32
| Professional | | $29.51 | $2,570.40 | $5,370.32 |