- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $1,023.29
| Professional | | $501.19 | $645.65 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | 50 | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $851.14
| Professional | | $724.44 | $724.44 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $954.99 / $7,079.46
| Professional | | $851.14 | $954.99 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $912.01
| Professional | | $501.19 | $776.25 | $912.01 |
- 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
- $549.54 / $724.44 / $1,071.52
| Professional | | $549.54 | $724.44 | $1,071.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $3,311.31 / $7,585.78
| Professional | | $616.60 | $3,311.31 | $7,585.78 |