- 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
- $1,819.70 / $1,905.46 / $2,344.23
| Professional | | $1,819.70 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $2,187.76
| Professional | | $1,778.28 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $3,388.44
| Professional | | $2,511.89 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,398.83
| Professional | | $1,737.80 | $1,905.46 | $2,398.83 |
- 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 / $2,238.72 / $2,884.03
| Professional | | $1,778.28 | $2,238.72 | $2,884.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,862.09 / $2,951.21
| Professional | | $29.51 | $1,862.09 | $2,951.21 |