- 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
- $891.25 / $1,000.00 / $1,445.44
| Professional | | $891.25 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $3,981.07
| Professional | | $912.01 | $1,202.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $11,748.98
| Professional | | $1,348.96 | $1,548.82 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $1,548.82
| Professional | | $1,023.29 | $1,230.27 | $1,548.82 |
- 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
- $831.76 / $1,230.27 / $1,698.24
| Professional | | $831.76 | $1,230.27 | $1,698.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $933.25 / $1,819.70
| Professional | | $29.51 | $933.25 | $1,819.70 |