- 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
- $457.09 / $616.60 / $977.24
| Professional | | $457.09 | $616.60 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $812.83
| Professional | | $691.83 | $691.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $4,677.35
| Professional | | $776.25 | $912.01 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $741.31 / $870.96
| Professional | | $457.09 | $741.31 | $870.96 |
- 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
- $478.63 / $691.83 / $1,023.29
| Professional | | $478.63 | $691.83 | $1,023.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $3,311.31 / $7,585.78
| Professional | | $562.34 | $3,311.31 | $7,585.78 |