- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,128.31 / $8,128.31
| Facility | | $2,818.38 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $812.83
| Professional | | $616.60 | $660.69 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $794.33 / $1,071.52
| Professional | | $758.58 | $794.33 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $13,803.84 / $18,197.01
| Professional | | $831.76 | $13,803.84 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $758.58
| Professional | | $588.84 | $645.65 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $794.33 / $1,023.29
| Professional | | $616.60 | $794.33 | $1,023.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $6,025.60 / $13,182.57
| Professional | | $562.34 | $6,025.60 | $13,182.57 |