- 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
- $223.87 / $354.81 / $616.60
| Professional | | $223.87 | $354.81 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $489.78
| Professional | | $426.58 | $426.58 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $478.63 / $5,248.07
| Professional | | $371.54 | $478.63 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $537.03
| Professional | | $223.87 | $407.38 | $537.03 |
- 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
- $275.42 / $457.09 / $660.69
| Professional | | $275.42 | $457.09 | $660.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $2,041.74 / $5,370.32
| Professional | | $302.00 | $2,041.74 | $5,370.32 |