- 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
- $870.96 / $977.24 / $1,348.96
| Professional | | $870.96 | $977.24 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,318.26
| Professional | | $933.25 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $7,762.47
| Professional | | $1,318.26 | $1,584.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,348.96
| Professional | | $954.99 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $1,548.82
| Professional | | $758.58 | $1,230.27 | $1,548.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,677.35 / $9,332.54
| Professional | | $1,174.90 | $4,677.35 | $9,332.54 |