- 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
- $234.42 / $354.81 / $575.44
| Professional | | $234.42 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $407.38 / $537.03
| Professional | | $257.04 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $549.54 / $4,570.88
| Professional | | $446.68 | $549.54 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $436.52 / $549.54
| Professional | | $275.42 | $436.52 | $549.54 |
- 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
- $288.40 / $436.52 / $602.56
| Professional | | $288.40 | $436.52 | $602.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $2,089.30 / $5,370.32
| Professional | | $363.08 | $2,089.30 | $5,370.32 |