- 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
- $323.59 / $501.19 / $812.83
| Professional | | $323.59 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $645.65 / $870.96
| Professional | | $407.38 | $645.65 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $630.96 / $776.25
| Professional | | $537.03 | $630.96 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $741.31 / $912.01
| Professional | | $416.87 | $741.31 | $912.01 |
- 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
- $302.00 / $537.03 / $794.33
| Professional | | $302.00 | $537.03 | $794.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $2,041.74 / $5,370.32
| Professional | | $489.78 | $2,041.74 | $5,370.32 |