- 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
- $645.65 / $724.44 / $977.24
| Professional | | $645.65 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $977.24
| Professional | | $691.83 | $831.76 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $831.76 / $7,762.47
| Professional | | $707.95 | $831.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $776.25 / $977.24
| Professional | | $691.83 | $776.25 | $977.24 |
- 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
- $501.19 / $724.44 / $1,148.15
| Professional | | $501.19 | $724.44 | $1,148.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $3,235.94 / $6,165.95
| Professional | | $724.44 | $3,235.94 | $6,165.95 |