- 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
- $512.86 / $616.60 / $977.24
| Professional | | $512.86 | $616.60 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $870.96
| Professional | | $707.95 | $707.95 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $1,258.93
| Professional | | $933.25 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,023.29
| Professional | | $676.08 | $851.14 | $1,023.29 |
- 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
- $562.34 / $851.14 / $1,122.02
| Professional | | $562.34 | $851.14 | $1,122.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,041.74 / $5,370.32
| Professional | | $645.65 | $2,041.74 | $5,370.32 |