- 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
- $489.78 / $602.56 / $851.14
| Professional | | $489.78 | $602.56 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $660.69 / $851.14
| Professional | | $602.56 | $660.69 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $870.96 / $1,071.52
| Professional | | $794.33 | $870.96 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $707.95 / $870.96
| Professional | | $616.60 | $707.95 | $870.96 |
- 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
- $467.74 / $676.08 / $977.24
| Professional | | $467.74 | $676.08 | $977.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,235.94 / $6,165.95
| Professional | | $741.31 | $3,235.94 | $6,165.95 |