- 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
- $3,311.31 / $4,265.80 / $5,495.41
| Professional | | $3,311.31 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,168.69 / $5,011.87
| Professional | | $3,388.44 | $4,168.69 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,888.44 / $7,079.46
| Professional | | $5,370.32 | $5,888.44 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,897.79 / $6,165.95
| Professional | | $4,466.84 | $4,897.79 | $6,165.95 |
- 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
- $4,073.80 / $4,786.30 / $6,606.93
| Professional | | $4,073.80 | $4,786.30 | $6,606.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $3,715.35 / $5,495.41
| Professional | | $29.51 | $3,715.35 | $5,495.41 |