- 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
- $549.54 / $588.84 / $933.25
| Professional | | $549.54 | $588.84 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $776.25
| Professional | | $549.54 | $691.83 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,311.31 / $5,623.41
| Professional | | $776.25 | $3,311.31 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $776.25
| Professional | | $549.54 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $933.25
| Professional | | $436.52 | $691.83 | $933.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $3,981.07 / $9,332.54
| Professional | | $676.08 | $3,981.07 | $9,332.54 |