- 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
- $204.17 / $295.12 / $426.58
| Professional | | $204.17 | $295.12 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $338.84 / $380.19
| Professional | | $239.88 | $338.84 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $436.52 / $7,079.46
| Professional | | $331.13 | $436.52 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $316.23 / $389.05
| Professional | | $208.93 | $316.23 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $346.74 / $426.58
| Professional | | $269.15 | $346.74 | $426.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $269.15 / $407.38
| Professional | | $51.29 | $269.15 | $407.38 |