- 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
- $524.81 / $575.44 / $812.83
| Professional | | $524.81 | $575.44 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $660.69 / $812.83
| Professional | | $575.44 | $660.69 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $1,023.29
| Professional | | $758.58 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $676.08 / $831.76
| Professional | | $588.84 | $676.08 | $831.76 |
- 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
- $446.68 / $645.65 / $912.01
| Professional | | $446.68 | $645.65 | $912.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $2,089.30 / $5,370.32
| Professional | | $660.69 | $2,089.30 | $5,370.32 |