- 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
- $354.81 / $478.63 / $776.25
| Professional | | $354.81 | $478.63 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $512.86 / $707.95
| Professional | | $426.58 | $512.86 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $2,398.83
| Professional | | $691.83 | $831.76 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $741.31
| Professional | | $389.05 | $602.56 | $741.31 |
- 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
- $302.00 / $575.44 / $724.44
| Professional | | $302.00 | $575.44 | $724.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $2,041.74 / $5,370.32
| Professional | | $446.68 | $2,041.74 | $5,370.32 |