- 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
- $588.84 / $660.69 / $977.24
| Professional | | $588.84 | $660.69 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $2,454.71
| Professional | | $645.65 | $870.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $954.99 / $1,148.15
| Professional | | $851.14 | $954.99 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $741.31 / $933.25
| Professional | | $616.60 | $741.31 | $933.25 |
- 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
- $616.60 / $794.33 / $1,096.48
| Professional | | $616.60 | $794.33 | $1,096.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $776.25 / $870.96
| Professional | | $109.65 | $776.25 | $870.96 |