- 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
- $190.55 / $275.42 / $549.54
| Professional | | $190.55 | $275.42 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $407.38
| Professional | | $331.13 | $331.13 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $467.74 / $4,570.88
| Professional | | $380.19 | $467.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $371.54 / $416.87
| Professional | | $218.78 | $371.54 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $354.81 / $524.81
| Professional | | $245.47 | $354.81 | $524.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $363.08 / $5,495.41
| Professional | | $54.95 | $363.08 | $5,495.41 |