- 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
- $426.58 / $512.86 / $831.76
| Professional | | $426.58 | $512.86 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $758.58
| Professional | | $616.60 | $616.60 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $2,570.40
| Professional | | $870.96 | $1,023.29 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $691.83 / $812.83
| Professional | | $524.81 | $691.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $954.99
| Professional | | $446.68 | $616.60 | $954.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $2,691.53 / $6,165.95
| Professional | | $562.34 | $2,691.53 | $6,165.95 |