- 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
- $251.19 / $302.00 / $407.38
| Professional | | $251.19 | $302.00 | $407.38 |
- 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
- $281.84 / $389.05 / $1,047.13
| Professional | | $281.84 | $389.05 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $501.19 / $2,398.83
| Professional | | $436.52 | $501.19 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $295.12 / $371.54
| Professional | | $251.19 | $295.12 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $354.81 / $562.34
| Professional | | $269.15 | $354.81 | $562.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $2,089.30 / $5,370.32
| Professional | | $354.81 | $2,089.30 | $5,370.32 |