- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $426.58 / $588.84
| Professional | | $389.05 | $426.58 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $489.78 / $602.56
| Professional | | $426.58 | $489.78 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $676.08 / $7,943.28
| Professional | | $588.84 | $676.08 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $645.65
| Professional | | $457.09 | $512.86 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $478.63 / $676.08
| Professional | | $323.59 | $478.63 | $676.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $4,073.80 / $7,943.28
| Professional | | $512.86 | $4,073.80 | $7,943.28 |