- 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
- $281.84 / $389.05 / $602.56
| Professional | | $281.84 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $446.68 / $616.60
| Professional | | $363.08 | $446.68 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $3,981.07
| Professional | | $512.86 | $602.56 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $602.56
| Professional | | $323.59 | $489.78 | $602.56 |
- 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
- $251.19 / $446.68 / $575.44
| Professional | | $251.19 | $446.68 | $575.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,995.26 / $5,370.32
| Professional | | $371.54 | $1,995.26 | $5,370.32 |