- 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
- $223.87 / $288.40 / $380.19
| Professional | | $223.87 | $288.40 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | 50 | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $316.23
| Professional | | $269.15 | $269.15 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $457.09 / $2,691.53
| Professional | | $354.81 | $457.09 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $288.40 / $346.74
| Professional | | $194.98 | $288.40 | $346.74 |
- 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
- $251.19 / $316.23 / $407.38
| Professional | | $251.19 | $316.23 | $407.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $1,621.81 / $3,981.07
| Professional | | $229.09 | $1,621.81 | $3,981.07 |