- 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
- $398.11 / $512.86 / $707.95
| Professional | | $398.11 | $512.86 | $707.95 |
- 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
- $676.08 / $741.31 / $891.25
| Professional | | $676.08 | $741.31 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $776.25
| Professional | | $549.54 | $616.60 | $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
- $389.05 / $549.54 / $812.83
| Professional | | $389.05 | $549.54 | $812.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $3,235.94 / $6,165.95
| Professional | | $691.83 | $3,235.94 | $6,165.95 |