- 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
- $302.00 / $616.60 / $1,096.48
| Professional | | $302.00 | $616.60 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $446.68 / $489.78 / $741.31
| Professional | 50 | $446.68 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $776.25 / $1,096.48
| Professional | | $346.74 | $776.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $776.25 / $3,981.07
| Professional | | $616.60 | $776.25 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $831.76 / $1,047.13
| Professional | | $295.12 | $831.76 | $1,047.13 |
- 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
- $251.19 / $602.56 / $1,548.82
| Professional | | $251.19 | $602.56 | $1,548.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $2,570.40 / $6,165.95
| Professional | | $407.38 | $2,570.40 | $6,165.95 |