- 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
- $478.63 / $537.03 / $741.31
| Professional | | $478.63 | $537.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $630.96 / $741.31
| Professional | | $524.81 | $630.96 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $776.25 / $933.25
| Professional | | $707.95 | $776.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $630.96 / $776.25
| Professional | | $549.54 | $630.96 | $776.25 |
- 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
- $416.87 / $630.96 / $851.14
| Professional | | $416.87 | $630.96 | $851.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $3,235.94 / $6,165.95
| Professional | | $724.44 | $3,235.94 | $6,165.95 |