- 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
- $239.88 / $331.13 / $457.09
| Professional | | $239.88 | $331.13 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $380.19
| Professional | | $316.23 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $436.52 / $537.03
| Professional | | $407.38 | $436.52 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $316.23 / $389.05
| Professional | | $288.40 | $316.23 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $389.05 / $489.78
| Professional | | $309.03 | $389.05 | $489.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $4,677.35 / $9,332.54
| Professional | | $407.38 | $4,677.35 | $9,332.54 |