- 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
- $363.08 / $478.63 / $676.08
| Professional | | $363.08 | $478.63 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $676.08
| Professional | | $478.63 | $537.03 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $707.95 / $851.14
| Professional | | $645.65 | $707.95 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $575.44 / $724.44
| Professional | | $512.86 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $776.25
| Professional | | $371.54 | $524.81 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $457.09 / $660.69
| Professional | | $29.51 | $457.09 | $660.69 |