- 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
- $1,148.15 / $1,995.26 / $2,041.74
| Professional | | $1,148.15 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,187.76
| Professional | | $1,819.70 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $3,162.28
| Professional | | $2,398.83 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,659.59 / $1,949.84
| Professional | | $1,513.56 | $1,659.59 | $1,949.84 |
- 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 / $1,905.46 / $2,454.71
| Professional | | $1,479.11 | $1,905.46 | $2,454.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,041.74 / $3,019.95
| Professional | | $29.51 | $2,041.74 | $3,019.95 |