- 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
- $316.23 / $371.54 / $446.68
| Professional | | $316.23 | $371.54 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $436.52 / $457.09
| Professional | | $354.81 | $436.52 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $12,589.25
| Professional | | $501.19 | $645.65 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $398.11 / $501.19
| Professional | | $363.08 | $398.11 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $446.68 / $588.84
| Professional | | $380.19 | $446.68 | $588.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,235.94 / $6,165.95
| Professional | | $501.19 | $3,235.94 | $6,165.95 |