- 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
- $154.88 / $288.40 / $457.09
| Professional | | $154.88 | $288.40 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $275.42 / $398.11
| Professional | | $151.36 | $275.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $338.84 / $7,079.46
| Professional | | $245.47 | $338.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $331.13 / $416.87
| Professional | | $151.36 | $331.13 | $416.87 |
- 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
- $194.98 / $331.13 / $478.63
| Professional | | $194.98 | $331.13 | $478.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $1,995.26 / $5,370.32
| Professional | | $199.53 | $1,995.26 | $5,370.32 |