- 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
- $331.13 / $446.68 / $707.95
| Professional | | $331.13 | $446.68 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $707.95
| Professional | | $575.44 | $575.44 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $4,570.88
| Professional | | $645.65 | $776.25 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $794.33
| Professional | | $436.52 | $691.83 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $851.14
| Professional | | $389.05 | $575.44 | $851.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $3,801.89 / $9,332.54
| Professional | | $457.09 | $3,801.89 | $9,332.54 |