- 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
- $416.87 / $478.63 / $575.44
| Professional | | $416.87 | $478.63 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $630.96
| Professional | | $457.09 | $549.54 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $12,589.25
| Professional | | $676.08 | $870.96 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $549.54 / $691.83
| Professional | | $501.19 | $549.54 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $776.25
| Professional | | $512.86 | $588.84 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $446.68 / $724.44
| Professional | | $29.51 | $446.68 | $724.44 |