- 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
- $1,819.70 / $2,089.30 / $2,818.38
| Professional | | $1,819.70 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $2,754.23
| Professional | | $1,949.84 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $2,570.40
| Professional | | $1,949.84 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $2,754.23
| Professional | | $1,905.46 | $2,187.76 | $2,754.23 |
- 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
- $1,202.26 / $2,041.74 / $3,311.31
| Professional | | $1,202.26 | $2,041.74 | $3,311.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,698.24 / $2,754.23
| Professional | | $29.51 | $1,698.24 | $2,754.23 |