- 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
- $707.95 / $1,000.00 / $1,412.54
| Professional | | $707.95 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,230.27
| Professional | | $912.01 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $1,698.24
| Professional | | $1,288.25 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,412.54
| Professional | | $1,047.13 | $1,148.15 | $1,412.54 |
- 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
- $1,000.00 / $1,071.52 / $1,445.44
| Professional | | $1,000.00 | $1,071.52 | $1,445.44 |
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 |