- 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
- $309.03 / $467.74 / $724.44
| Professional | | $309.03 | $467.74 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $512.86 / $691.83
| Professional | | $407.38 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $3,981.07
| Professional | | $562.34 | $660.69 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $562.34 / $676.08
| Professional | | $363.08 | $562.34 | $676.08 |
- 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
- $281.84 / $512.86 / $676.08
| Professional | | $281.84 | $512.86 | $676.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $2,570.40 / $6,165.95
| Professional | | $436.52 | $2,570.40 | $6,165.95 |