- 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
- $269.15 / $323.59 / $446.68
| Professional | | $269.15 | $323.59 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $346.74 / $446.68
| Professional | | $316.23 | $346.74 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $501.19 / $5,011.87
| Professional | | $426.58 | $501.19 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $371.54 / $467.74
| Professional | | $302.00 | $371.54 | $467.74 |
- 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
- $234.42 / $363.08 / $478.63
| Professional | | $234.42 | $363.08 | $478.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $2,570.40 / $6,165.95
| Professional | | $338.84 | $2,570.40 | $6,165.95 |