- 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
- $371.54 / $426.58 / $616.60
| Professional | | $371.54 | $426.58 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $478.63 / $645.65
| Professional | | $457.09 | $478.63 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $2,630.27
| Professional | | $602.56 | $691.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $724.44
| Professional | | $457.09 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $630.96
| Professional | | $331.13 | $478.63 | $630.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $446.68 / $602.56
| Professional | | $75.86 | $446.68 | $602.56 |