- 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
- $346.74 / $489.78 / $724.44
| Professional | | $346.74 | $489.78 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $660.69
| Professional | | $537.03 | $537.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $4,570.88
| Professional | | $602.56 | $741.31 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $616.60 / $691.83
| Professional | | $371.54 | $616.60 | $691.83 |
- 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
- $380.19 / $575.44 / $831.76
| Professional | | $380.19 | $575.44 | $831.76 |
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 |