- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,466.84 / $4,466.84
| Facility | | $1,318.26 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $616.60 / $977.24
| Professional | | $331.13 | $616.60 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $741.31 / $812.83
| Professional | | $645.65 | $741.31 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $7,943.28
| Professional | | $691.83 | $912.01 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $933.25
| Professional | | $691.83 | $758.58 | $933.25 |
- 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
- $660.69 / $758.58 / $1,047.13
| Professional | | $660.69 | $758.58 | $1,047.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $3,715.35 / $6,165.95
| Professional | | $831.76 | $3,715.35 | $6,165.95 |