- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $707.95
| Professional | | $398.11 | $467.74 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $588.84
| Professional | | $512.86 | $512.86 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $831.76 / $2,691.53
| Professional | | $645.65 | $831.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $691.83
| Professional | | $407.38 | $537.03 | $691.83 |
- 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
- $426.58 / $524.81 / $741.31
| Professional | | $426.58 | $524.81 | $741.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $3,311.31 / $7,585.78
| Professional | | $489.78 | $3,311.31 | $7,585.78 |