- 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
- $354.81 / $407.38 / $537.03
| Professional | | $354.81 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $446.68 / $537.03
| Professional | | $380.19 | $446.68 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $7,943.28
| Professional | | $512.86 | $588.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $467.74 / $588.84
| Professional | | $416.87 | $467.74 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $446.68 / $630.96
| Professional | | $309.03 | $446.68 | $630.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $3,235.94 / $6,165.95
| Professional | | $512.86 | $3,235.94 | $6,165.95 |