- 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
- $288.40 / $316.23 / $398.11
| Professional | | $288.40 | $316.23 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $363.08 / $426.58
| Professional | | $302.00 | $363.08 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $602.56 / $7,943.28
| Professional | | $467.74 | $602.56 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $363.08 / $457.09
| Professional | | $338.84 | $363.08 | $457.09 |
- 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
- $346.74 / $398.11 / $524.81
| Professional | | $346.74 | $398.11 | $524.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $3,235.94 / $6,165.95
| Professional | | $467.74 | $3,235.94 | $6,165.95 |