- 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
- $676.08 / $741.31 / $933.25
| Professional | | $676.08 | $741.31 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $977.24
| Professional | | $724.44 | $870.96 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,380.38 / $7,943.28
| Professional | | $1,071.52 | $1,380.38 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $1,047.13
| Professional | | $776.25 | $831.76 | $1,047.13 |
- 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
- $794.33 / $954.99 / $1,258.93
| Professional | | $794.33 | $954.99 | $1,258.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $4,677.35 / $9,332.54
| Professional | | $954.99 | $4,677.35 | $9,332.54 |