- 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 / $575.44 / $812.83
| Professional | | $446.68 | $575.44 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $812.83
| Professional | | $575.44 | $602.56 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $1,023.29
| Professional | | $758.58 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $851.14
| Professional | | $602.56 | $676.08 | $851.14 |
- 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
- $446.68 / $630.96 / $933.25
| Professional | | $446.68 | $630.96 | $933.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $3,235.94 / $6,165.95
| Professional | | $794.33 | $3,235.94 | $6,165.95 |