- 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
- $389.05 / $489.78 / $794.33
| Professional | | $389.05 | $489.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $724.44
| Professional | | $457.09 | $549.54 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $7,079.46
| Professional | | $758.58 | $912.01 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $891.25
| Professional | | $501.19 | $676.08 | $891.25 |
- 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
- $501.19 / $588.84 / $851.14
| Professional | | $501.19 | $588.84 | $851.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $2,691.53 / $6,165.95
| Professional | | $524.81 | $2,691.53 | $6,165.95 |