- 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
- $478.63 / $512.86 / $602.56
| Professional | | $478.63 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $588.84
| Professional | | $467.74 | $575.44 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $7,943.28
| Professional | | $691.83 | $891.25 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $489.78 / $616.60
| Professional | | $446.68 | $489.78 | $616.60 |
- 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
- $467.74 / $602.56 / $741.31
| Professional | | $467.74 | $602.56 | $741.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $2,089.30 / $5,370.32
| Professional | | $512.86 | $2,089.30 | $5,370.32 |