- 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
- $338.84 / $446.68 / $724.44
| Professional | | $338.84 | $446.68 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $645.65
| Professional | | $524.81 | $524.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $7,079.46
| Professional | | $645.65 | $776.25 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $588.84 / $676.08
| Professional | | $363.08 | $588.84 | $676.08 |
- 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
- $398.11 / $588.84 / $831.76
| Professional | | $398.11 | $588.84 | $831.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,041.74 / $5,370.32
| Professional | | $467.74 | $2,041.74 | $5,370.32 |