- 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 / $380.19 / $575.44
| Professional | | $269.15 | $380.19 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $1,202.26
| Professional | | $302.00 | $457.09 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $562.34 / $676.08
| Professional | | $478.63 | $562.34 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $426.58 / $575.44
| Professional | | $295.12 | $426.58 | $575.44 |
- 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
- $288.40 / $416.87 / $645.65
| Professional | | $288.40 | $416.87 | $645.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $2,570.40 / $6,165.95
| Professional | | $363.08 | $2,570.40 | $6,165.95 |