- 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
- $1,230.27 / $1,380.38 / $1,949.84
| Professional | | $1,230.27 | $1,380.38 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $1,905.46
| Professional | | $1,348.96 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,344.23
| Professional | | $1,905.46 | $2,137.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,862.09
| Professional | | $1,318.26 | $1,513.56 | $1,862.09 |
- 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
- $1,096.48 / $1,584.89 / $2,238.72
| Professional | | $1,096.48 | $1,584.89 | $2,238.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,230.27 / $2,187.76
| Professional | | $29.51 | $1,230.27 | $2,187.76 |