- 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
- $162.18 / $281.84 / $831.76
| Professional | | $162.18 | $281.84 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $436.52
| Professional | | $354.81 | $354.81 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $416.87 / $2,454.71
| Professional | | $346.74 | $416.87 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $446.68
| Professional | | $204.17 | $363.08 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $331.13 / $537.03
| Professional | | $223.87 | $331.13 | $537.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $3,715.35 / $5,495.41
| Professional | | $239.88 | $3,715.35 | $5,495.41 |