- 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
- $1,584.89 / $1,698.24 / $2,344.23
| Professional | | $1,584.89 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,137.96
| Professional | | $1,819.70 | $2,041.74 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $3,090.30
| Professional | | $2,344.23 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $2,344.23
| Professional | | $1,698.24 | $1,862.09 | $2,344.23 |
- 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 / $2,137.96 / $2,818.38
| Professional | | $1,778.28 | $2,137.96 | $2,818.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,584.89 / $2,818.38
| Professional | | $29.51 | $1,584.89 | $2,818.38 |