- 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 / $281.84 / $457.09
| Professional | | $190.55 | $281.84 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $346.74 / $407.38
| Professional | | $218.78 | $346.74 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $457.09 / $4,570.88
| Professional | | $371.54 | $457.09 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $457.09
| Professional | | $239.88 | $371.54 | $457.09 |
- 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
- $251.19 / $354.81 / $478.63
| Professional | | $251.19 | $354.81 | $478.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $2,089.30 / $5,370.32
| Professional | | $316.23 | $2,089.30 | $5,370.32 |