- 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
- $436.52 / $537.03 / $851.14
| Professional | | $436.52 | $537.03 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $812.83
| Professional | | $660.69 | $660.69 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $933.25 / $1,122.02
| Professional | | $851.14 | $933.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $724.44 / $851.14
| Professional | | $660.69 | $724.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $741.31 / $977.24
| Professional | | $489.78 | $741.31 | $977.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $3,235.94 / $6,165.95
| Professional | | $758.58 | $3,235.94 | $6,165.95 |