- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,955.10 / $2,955.10 / $2,955.10
| Facility | | $2,955.10 | $2,955.10 | $2,955.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $2,056.78 / $6,394.72
| Professional | | $1,730.31 | $2,056.78 | $6,394.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,955.10 / $2,955.10 / $2,955.10
| Facility | | $2,955.10 | $2,955.10 | $2,955.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.50 / $2,433.50 / $2,433.50
| Professional | | $2,433.50 | $2,433.50 | $2,433.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.36 / $2,076.39 / $2,422.44
| Professional | | $1,903.36 | $2,076.39 | $2,422.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.21 / $2,000.13 / $2,595.48
| Professional | | $1,926.21 | $2,000.13 | $2,595.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.93 / $1,617.65 / $2,016.80
| Professional | | $1,031.93 | $1,617.65 | $2,016.80 |