- 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
- $218.78 / $354.81 / $758.58
| Professional | | $218.78 | $354.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $549.54
| Professional | | $446.68 | $446.68 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $630.96 / $4,570.88
| Professional | | $457.09 | $630.96 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $457.09 / $562.34
| Professional | | $263.03 | $457.09 | $562.34 |
- 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
- $323.59 / $457.09 / $707.95
| Professional | | $323.59 | $457.09 | $707.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $398.11 / $3,548.13
| Professional | | $75.86 | $398.11 | $3,548.13 |