- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $436.52 / $1,047.13
| Professional | | $257.04 | $436.52 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $645.65
| Professional | | $524.81 | $524.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $758.58 / $4,570.88
| Professional | | $575.44 | $758.58 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $549.54 / $645.65
| Professional | | $309.03 | $549.54 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $549.54 / $831.76
| Professional | | $389.05 | $549.54 | $831.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $5,011.87 / $6,606.93
| Professional | | $354.81 | $5,011.87 | $6,606.93 |