- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $363.08 / $549.54
| Professional | | $223.87 | $363.08 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $380.19 / $1,071.52
| Professional | | $229.09 | $380.19 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $457.09 / $575.44
| Professional | | $389.05 | $457.09 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $602.56
| Professional | | $407.38 | $489.78 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $407.38 / $562.34
| Professional | | $239.88 | $407.38 | $562.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,412.54 / $3,981.07
| Professional | | $295.12 | $1,412.54 | $3,981.07 |