- 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
- $173.78 / $281.84 / $302.00
| Professional | | $173.78 | $281.84 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $323.59
| Professional | | $281.84 | $281.84 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $3,890.45 / $5,623.41
| Professional | | $363.08 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $257.04 / $302.00
| Professional | | $234.42 | $257.04 | $302.00 |
- 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
- $229.09 / $281.84 / $363.08
| Professional | | $229.09 | $281.84 | $363.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $3,235.94 / $6,165.95
| Professional | | $323.59 | $3,235.94 | $6,165.95 |