- 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
- $346.74 / $380.19 / $446.68
| Professional | | $346.74 | $380.19 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $416.87 / $426.58
| Professional | | $338.84 | $416.87 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $602.56 / $741.31
| Professional | | $562.34 | $602.56 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $363.08 / $446.68
| Professional | | $331.13 | $363.08 | $446.68 |
- 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 / $446.68 / $549.54
| Professional | | $338.84 | $446.68 | $549.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $2,691.53 / $6,165.95
| Professional | | $416.87 | $2,691.53 | $6,165.95 |