- 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 / $831.76 / $2,511.89
| Professional | | $645.65 | $831.76 | $2,511.89 |
- 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
- $630.96 / $758.58 / $933.25
| Professional | | $630.96 | $758.58 | $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
- $588.84 / $812.83 / $1,096.48
| Professional | | $588.84 | $812.83 | $1,096.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $645.65 / $1,047.13
| Professional | | $109.65 | $645.65 | $1,047.13 |