- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $8,511.38
| Facility | | $2,818.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $616.60 / $707.95
| Professional | | $346.74 | $616.60 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $660.69
| Professional | | $616.60 | $616.60 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $5,888.44 / $8,317.64
| Professional | | $758.58 | $5,888.44 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $537.03 / $616.60
| Professional | | $489.78 | $537.03 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $630.96 / $812.83
| Professional | | $501.19 | $630.96 | $812.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $5,888.44 / $9,332.54
| Professional | | $645.65 | $5,888.44 | $9,332.54 |