- 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
- $478.63 / $549.54 / $660.69
| Professional | | $478.63 | $549.54 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $645.65 / $707.95
| Professional | | $524.81 | $645.65 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $12,589.25
| Professional | | $776.25 | $1,000.00 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $602.56 / $758.58
| Professional | | $549.54 | $602.56 | $758.58 |
- 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 / $676.08 / $891.25
| Professional | | $575.44 | $676.08 | $891.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $512.86 / $851.14
| Professional | | $29.51 | $512.86 | $851.14 |