- 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
- $389.05 / $478.63 / $588.84
| Professional | | $389.05 | $478.63 | $588.84 |
- 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
- $707.95 / $933.25 / $5,495.41
| Professional | | $707.95 | $933.25 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $512.86 / $645.65
| Professional | | $478.63 | $512.86 | $645.65 |
- 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
- $489.78 / $602.56 / $776.25
| Professional | | $489.78 | $602.56 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $436.52 / $851.14
| Professional | | $29.51 | $436.52 | $851.14 |