- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $363.08 / $562.34
| Professional | | $245.47 | $363.08 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $501.19
| Professional | | $407.38 | $407.38 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $4,570.88
| Professional | | $467.74 | $575.44 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $457.09 / $524.81
| Professional | | $269.15 | $457.09 | $524.81 |
- 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
- $302.00 / $446.68 / $645.65
| Professional | | $302.00 | $446.68 | $645.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $2,041.74 / $5,370.32
| Professional | | $363.08 | $2,041.74 | $5,370.32 |