- 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
- $602.56 / $660.69 / $933.25
| Professional | | $602.56 | $660.69 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $912.01
| Professional | | $645.65 | $758.58 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,023.29
| Professional | | $912.01 | $912.01 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $954.99
| Professional | | $676.08 | $758.58 | $954.99 |
- 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
- $512.86 / $707.95 / $1,047.13
| Professional | | $512.86 | $707.95 | $1,047.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $2,691.53 / $6,165.95
| Professional | | $758.58 | $2,691.53 | $6,165.95 |