- 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
- $302.00 / $446.68 / $758.58
| Professional | | $302.00 | $446.68 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $524.81 / $707.95
| Professional | | $380.19 | $524.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $3,981.07
| Professional | | $562.34 | $676.08 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $588.84 / $724.44
| Professional | | $371.54 | $588.84 | $724.44 |
- 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
- $281.84 / $512.86 / $645.65
| Professional | | $281.84 | $512.86 | $645.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $2,041.74 / $5,370.32
| Professional | | $407.38 | $2,041.74 | $5,370.32 |