- 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
- $281.84 / $426.58 / $707.95
| Professional | | $281.84 | $426.58 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $512.86 / $707.95
| Professional | | $363.08 | $512.86 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $676.08 / $2,137.96
| Professional | | $524.81 | $676.08 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $724.44
| Professional | | $338.84 | $588.84 | $724.44 |
- 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
- $257.04 / $489.78 / $645.65
| Professional | | $257.04 | $489.78 | $645.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $2,041.74 / $5,370.32
| Professional | | $416.87 | $2,041.74 | $5,370.32 |