- 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
- $323.59 / $954.99 / $2,754.23
| Professional | | $323.59 | $954.99 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,949.84 / $2,344.23
| Professional | | $398.11 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $2,951.21
| Professional | | $588.84 | $724.44 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,905.46 / $2,398.83
| Professional | | $338.84 | $1,905.46 | $2,398.83 |
- 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
- $457.09 / $1,905.46 / $2,630.27
| Professional | | $457.09 | $1,905.46 | $2,630.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $467.74 / $2,754.23
| Professional | | $316.23 | $467.74 | $2,754.23 |