- 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
- $724.44 / $812.83 / $1,096.48
| Professional | | $724.44 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $1,096.48
| Professional | | $776.25 | $912.01 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,380.38
| Professional | | $1,047.13 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $1,122.02
| Professional | | $794.33 | $891.25 | $1,122.02 |
- 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
- $616.60 / $912.01 / $1,258.93
| Professional | | $616.60 | $912.01 | $1,258.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $4,677.35 / $9,332.54
| Professional | | $954.99 | $4,677.35 | $9,332.54 |