- 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
- $4,365.16 / $5,128.61 / $7,413.10
| Professional | | $4,365.16 | $5,128.61 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $17,782.79
| Professional | | $3,311.31 | $5,888.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,079.46 / $8,317.64
| Professional | | $6,309.57 | $7,079.46 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,248.07 / $6,606.93
| Professional | | $4,365.16 | $5,248.07 | $6,606.93 |
- 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
- $3,890.45 / $6,025.60 / $7,943.28
| Professional | | $3,890.45 | $6,025.60 | $7,943.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $4,265.80 / $6,456.54
| Professional | | $29.51 | $4,265.80 | $6,456.54 |