- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $398.11 / $724.44
| Professional | | $275.42 | $398.11 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $645.65
| Professional | | $537.03 | $537.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $676.08
| Professional | | $549.54 | $616.60 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $588.84 / $724.44
| Professional | | $331.13 | $588.84 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $831.76
| Professional | | $380.19 | $537.03 | $831.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $407.38 / $616.60
| Professional | | $89.13 | $407.38 | $616.60 |