- 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
- $1,318.26 / $2,344.23 / $3,548.13
| Professional | | $1,318.26 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,467.37 / $8,912.51
| Professional | | $1,949.84 | $3,467.37 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $2,570.40
| Professional | | $1,737.80 | $2,089.30 | $2,570.40 |
- 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
- $1,778.28 / $2,454.71 / $3,715.35
| Professional | | $1,778.28 | $2,454.71 | $3,715.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $29.51 / $29.51
| Professional | | $29.51 | $29.51 | $29.51 |