- 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
- $2,238.72 / $2,570.40 / $3,467.37
| Professional | | $2,238.72 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,388.44
| Professional | | $2,398.83 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $3,467.37
| Professional | | $2,630.27 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $3,311.31
| Professional | | $2,344.23 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $3,981.07
| Professional | | $1,905.46 | $2,511.89 | $3,981.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,238.72 / $3,311.31
| Professional | | $29.51 | $2,238.72 | $3,311.31 |