- 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
- $3,311.31 / $3,801.89 / $5,495.41
| Professional | | $3,311.31 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,786.30 / $13,803.84
| Professional | | $3,548.13 | $4,786.30 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,025.60 / $6,309.57
| Professional | | $5,623.41 | $6,025.60 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $5,011.87
| Professional | | $3,311.31 | $3,981.07 | $5,011.87 |
- 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
- $3,548.13 / $4,677.35 / $6,309.57
| Professional | | $3,548.13 | $4,677.35 | $6,309.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $4,365.16 / $4,897.79
| Professional | | $602.56 | $4,365.16 | $4,897.79 |