- 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
- $1,698.24 / $1,949.84 / $2,398.83
| Professional | | $1,698.24 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,454.71
| Professional | | $1,737.80 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $14,454.40
| Professional | | $2,398.83 | $2,818.38 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,630.27
| Professional | | $1,862.09 | $2,089.30 | $2,630.27 |
- 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
- $1,445.44 / $2,137.96 / $2,884.03
| Professional | | $1,445.44 | $2,137.96 | $2,884.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,778.28 / $2,454.71
| Professional | | $29.51 | $1,778.28 | $2,454.71 |