- 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
- $151.36 / $218.78 / $478.63
| Professional | | $151.36 | $218.78 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $338.84
| Professional | | $275.42 | $275.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $371.54 / $4,570.88
| Professional | | $295.12 | $371.54 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $338.84 / $389.05
| Professional | | $199.53 | $338.84 | $389.05 |
- 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
- $190.55 / $275.42 / $416.87
| Professional | | $190.55 | $275.42 | $416.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $2,041.74 / $5,370.32
| Professional | | $229.09 | $2,041.74 | $5,370.32 |