- 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
- $4,168.69 / $4,677.35 / $7,079.46
| Professional | | $4,168.69 | $4,677.35 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,754.40 / $17,378.01
| Professional | | $4,570.88 | $5,754.40 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,760.83 / $7,943.28
| Professional | | $6,025.60 | $6,760.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,128.61 / $6,309.57
| Professional | | $4,265.80 | $5,128.61 | $6,309.57 |
- 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
- $4,265.80 / $5,754.40 / $7,585.78
| Professional | | $4,265.80 | $5,754.40 | $7,585.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $4,365.16 / $7,079.46
| Professional | | $29.51 | $4,365.16 | $7,079.46 |