- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $588.84 / $794.33
| Professional | | $416.87 | $588.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $660.69
| Professional | | $549.54 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $977.24
| Professional | | $758.58 | $831.76 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $549.54 / $676.08
| Professional | | $501.19 | $549.54 | $676.08 |
- 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
- $549.54 / $660.69 / $870.96
| Professional | | $549.54 | $660.69 | $870.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $4,570.88 / $7,943.28
| Professional | | $724.44 | $4,570.88 | $7,943.28 |