- 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
- $380.19 / $436.52 / $2,137.96
| Professional | | $380.19 | $436.52 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $575.44
| Professional | | $407.38 | $489.78 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $4,897.79
| Professional | | $602.56 | $758.58 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $489.78 / $616.60
| Professional | | $436.52 | $489.78 | $616.60 |
- 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
- $331.13 / $524.81 / $676.08
| Professional | | $331.13 | $524.81 | $676.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $2,454.71 / $4,073.80
| Professional | | $501.19 | $2,454.71 | $4,073.80 |