- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,025.60 / $6,025.60
| Facility | | $2,570.40 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $2,398.83
| Professional | | $1,412.54 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,344.23
| Professional | | $1,659.59 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $2,951.21
| Professional | | $2,344.23 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $2,238.72
| Professional | | $1,584.89 | $1,819.70 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $2,754.23
| Professional | | $1,380.38 | $1,995.26 | $2,754.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,513.56 / $2,818.38
| Professional | | $29.51 | $1,513.56 | $2,818.38 |