- 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
- $5,370.32 / $5,754.40 / $6,456.54
| Professional | | $5,370.32 | $5,754.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,606.93 / $7,244.36
| Professional | | $6,025.60 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $8,317.64 / $10,000.00
| Professional | | $7,585.78 | $8,317.64 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,165.95 / $7,585.78
| Professional | | $5,623.41 | $6,165.95 | $7,585.78 |
- 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
- $5,495.41 / $6,760.83 / $9,120.11
| Professional | | $5,495.41 | $6,760.83 | $9,120.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $6,918.31 / $8,912.51
| Professional | | $29.51 | $6,918.31 | $8,912.51 |