- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $512.86 / $691.83
| Professional | | $426.58 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $724.44
| Professional | | $512.86 | $537.03 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $741.31 / $912.01
| Professional | | $691.83 | $741.31 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $630.96 / $794.33
| Professional | | $549.54 | $630.96 | $794.33 |
- 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
- $363.08 / $537.03 / $776.25
| Professional | | $363.08 | $537.03 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $2,089.30 / $5,370.32
| Professional | | $537.03 | $2,089.30 | $5,370.32 |