- 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
- $446.68 / $501.19 / $691.83
| Professional | | $446.68 | $501.19 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $575.44 / $691.83
| Professional | | $489.78 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $3,311.31 / $5,623.41
| Professional | | $676.08 | $3,311.31 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $575.44 / $724.44
| Professional | | $512.86 | $575.44 | $724.44 |
- 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
- $380.19 / $562.34 / $794.33
| Professional | | $380.19 | $562.34 | $794.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $3,235.94 / $6,165.95
| Professional | | $660.69 | $3,235.94 | $6,165.95 |