- 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
- $354.81 / $501.19 / $758.58
| Professional | | $354.81 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $537.03 / $724.44
| Professional | | $416.87 | $537.03 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $794.33
| Professional | | $575.44 | $691.83 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $691.83
| Professional | | $371.54 | $562.34 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $537.03 / $776.25
| Professional | | $288.40 | $537.03 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,570.40 / $6,165.95
| Professional | | $467.74 | $2,570.40 | $6,165.95 |