- 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
- $269.15 / $524.81 / $831.76
| Professional | | $269.15 | $524.81 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $501.19 / $776.25
| Professional | | $263.03 | $501.19 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $9,120.11
| Professional | | $426.58 | $575.44 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $630.96 / $794.33
| Professional | | $251.19 | $630.96 | $794.33 |
- 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
- $338.84 / $616.60 / $1,698.24
| Professional | | $338.84 | $616.60 | $1,698.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $2,041.74 / $5,370.32
| Professional | | $338.84 | $2,041.74 | $5,370.32 |