- 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
- $154.88 / $194.98 / $275.42
| Professional | | $154.88 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $190.55 / $295.12
| Professional | | $158.49 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $331.13 / $7,943.28
| Professional | | $281.84 | $331.13 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $234.42 / $302.00
| Professional | | $173.78 | $234.42 | $302.00 |
- 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
- $194.98 / $239.88 / $338.84
| Professional | | $194.98 | $239.88 | $338.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $2,041.74 / $5,370.32
| Professional | | $213.80 | $2,041.74 | $5,370.32 |