- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $707.95
| Professional | | $457.09 | $512.86 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $707.95
| Professional | | $501.19 | $575.44 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $7,762.47
| Professional | | $676.08 | $794.33 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $602.56 / $758.58
| Professional | | $537.03 | $602.56 | $758.58 |
- 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
- $389.05 / $562.34 / $812.83
| Professional | | $389.05 | $562.34 | $812.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $4,073.80 / $7,943.28
| Professional | | $588.84 | $4,073.80 | $7,943.28 |