- 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
- $3,235.94 / $5,888.44 / $6,309.57
| Professional | | $3,235.94 | $5,888.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,606.93 / $7,943.28
| Professional | | $6,165.95 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,370.32 / $6,165.95
| Professional | | $4,897.79 | $5,370.32 | $6,165.95 |
- 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
- $4,365.16 / $5,623.41 / $7,585.78
| Professional | | $4,365.16 | $5,623.41 | $7,585.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $4,365.16 / $6,309.57
| Professional | | $29.51 | $4,365.16 | $6,309.57 |