- 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
- $371.54 / $489.78 / $741.31
| Professional | | $371.54 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $588.84 / $794.33
| Professional | | $457.09 | $588.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $3,981.07
| Professional | | $676.08 | $758.58 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $831.76
| Professional | | $436.52 | $676.08 | $831.76 |
- 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
- $338.84 / $575.44 / $724.44
| Professional | | $338.84 | $575.44 | $724.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $2,511.89 / $6,165.95
| Professional | | $512.86 | $2,511.89 | $6,165.95 |