- 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
- $316.23 / $346.74 / $478.63
| Professional | | $316.23 | $346.74 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $389.05 / $489.78
| Professional | | $346.74 | $389.05 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $5,011.87
| Professional | | $467.74 | $549.54 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $426.58 / $524.81
| Professional | | $371.54 | $426.58 | $524.81 |
- 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
- $263.03 / $380.19 / $549.54
| Professional | | $263.03 | $380.19 | $549.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $2,089.30 / $5,370.32
| Professional | | $426.58 | $2,089.30 | $5,370.32 |