- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $707.95
| Professional | | $302.00 | $457.09 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $691.83
| Professional | | $389.05 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $3,981.07
| Professional | | $549.54 | $660.69 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $676.08
| Professional | | $354.81 | $549.54 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $512.86 / $676.08
| Professional | | $275.42 | $512.86 | $676.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $3,311.31 / $7,585.78
| Professional | | $446.68 | $3,311.31 | $7,585.78 |