- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $208.93 / $851.14
| Professional | | $43.65 | $208.93 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $102.33 / $354.81
| Professional | | $50.12 | $102.33 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $95.50 / $2,344.23
| Professional | | $70.79 | $95.50 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $229.09 / $288.40
| Professional | | $40.74 | $229.09 | $288.40 |
- 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
- $42.66 / $151.36 / $281.84
| Professional | | $42.66 | $151.36 | $281.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.41 / $53.70 / $295.12
| Professional | | $7.41 | $53.70 | $295.12 |