- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $891.25
| Professional | | $575.44 | $630.96 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $741.31 / $870.96
| Professional | | $616.60 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $977.24 / $7,943.28
| Professional | | $851.14 | $977.24 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $912.01
| Professional | | $645.65 | $724.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $724.44 / $1,000.00
| Professional | | $489.78 | $724.44 | $1,000.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,691.53 / $6,165.95
| Professional | | $741.31 | $2,691.53 | $6,165.95 |