- 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
- $1,905.46 / $2,187.76 / $3,235.94
| Professional | | $1,905.46 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $8,128.31
| Professional | | $1,995.26 | $2,630.27 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $3,801.89
| Professional | | $2,951.21 | $3,630.78 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,090.30
| Professional | | $2,041.74 | $2,454.71 | $3,090.30 |
- 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
- $1,905.46 / $2,630.27 / $3,388.44
| Professional | | $1,905.46 | $2,630.27 | $3,388.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,949.84 / $2,884.03
| Professional | | $29.51 | $1,949.84 | $2,884.03 |