- 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
- $602.56 / $660.69 / $912.01
| Professional | | $602.56 | $660.69 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $912.01
| Professional | | $645.65 | $776.25 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $5,011.87
| Professional | | $851.14 | $1,000.00 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $891.25
| Professional | | $630.96 | $707.95 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $741.31 / $1,047.13
| Professional | | $512.86 | $741.31 | $1,047.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $794.33 / $12,882.50
| Professional | | $112.20 | $794.33 | $12,882.50 |