- 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
- $549.54 / $724.44 / $1,023.29
| Professional | | $549.54 | $724.44 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $1,023.29
| Professional | | $724.44 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,071.52 / $1,288.25
| Professional | | $977.24 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $1,047.13
| Professional | | $741.31 | $851.14 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $1,174.90
| Professional | | $575.44 | $891.25 | $1,174.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $3,235.94 / $6,165.95
| Professional | | $912.01 | $3,235.94 | $6,165.95 |