- 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
- $501.19 / $524.81 / $630.96
| Professional | | $501.19 | $524.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $588.84 / $602.56
| Professional | | $478.63 | $588.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $933.25 / $2,691.53
| Professional | | $724.44 | $933.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $537.03 / $676.08
| Professional | | $501.19 | $537.03 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $776.25
| Professional | | $501.19 | $602.56 | $776.25 |
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 |