- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $141.25
| Professional | | $83.18 | $97.72 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $120.23
| Professional | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $173.78
| Professional | | $100.00 | $123.03 | $173.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $29.51 / $29.51
| Professional | | $29.51 | $29.51 | $29.51 |