- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,818.38 / $3,890.45
| Facility | | $1,122.02 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $870.96
| Professional | | $213.80 | $316.23 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $407.38
| Professional | | $338.84 | $338.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $489.78 / $4,570.88
| Professional | | $416.87 | $489.78 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $389.05 / $446.68
| Professional | | $257.04 | $389.05 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $338.84 / $512.86
| Professional | | $239.88 | $338.84 | $512.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $2,041.74 / $5,370.32
| Professional | | $295.12 | $2,041.74 | $5,370.32 |