- 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
- $562.34 / $645.65 / $812.83
| Professional | | $562.34 | $645.65 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $691.83 / $707.95
| Professional | | $562.34 | $691.83 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $7,943.28
| Professional | | $851.14 | $1,096.48 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $794.33
| Professional | | $575.44 | $630.96 | $794.33 |
- 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
- $575.44 / $724.44 / $912.01
| Professional | | $575.44 | $724.44 | $912.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $3,235.94 / $6,165.95
| Professional | | $676.08 | $3,235.94 | $6,165.95 |