- 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 / $407.38 / $575.44
| Professional | | $371.54 | $407.38 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $457.09 / $575.44
| Professional | | $407.38 | $457.09 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $645.65 / $7,943.28
| Professional | | $562.34 | $645.65 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $501.19 / $616.60
| Professional | | $436.52 | $501.19 | $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
- $316.23 / $436.52 / $660.69
| Professional | | $316.23 | $436.52 | $660.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $2,691.53 / $6,165.95
| Professional | | $501.19 | $2,691.53 | $6,165.95 |