- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $831.76
| Professional | | $407.38 | $537.03 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $707.95
| Professional | | $602.56 | $602.56 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $5,011.87
| Professional | | $691.83 | $851.14 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $645.65 / $776.25
| Professional | | $436.52 | $645.65 | $776.25 |
- 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
- $467.74 / $602.56 / $851.14
| Professional | | $467.74 | $602.56 | $851.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $2,041.74 / $5,623.41
| Professional | | $489.78 | $2,041.74 | $5,623.41 |