- 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
- $776.25 / $870.96 / $1,202.26
| Professional | | $776.25 | $870.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,174.90
| Professional | | $831.76 | $977.24 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,479.11
| Professional | | $1,122.02 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $954.99 / $1,202.26
| Professional | | $851.14 | $954.99 | $1,202.26 |
- 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
- $676.08 / $1,023.29 / $1,348.96
| Professional | | $676.08 | $1,023.29 | $1,348.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,677.35 / $9,332.54
| Professional | | $1,023.29 | $4,677.35 | $9,332.54 |