- 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
- $588.84 / $707.95 / $954.99
| Professional | | $588.84 | $707.95 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $794.33
| Professional | | $691.83 | $691.83 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $2,691.53
| Professional | | $870.96 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $676.08 / $776.25
| Professional | | $616.60 | $676.08 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $776.25 / $1,023.29
| Professional | | $588.84 | $776.25 | $1,023.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $3,311.31 / $7,585.78
| Professional | | $630.96 | $3,311.31 | $7,585.78 |