- 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
- $213.80 / $251.19 / $302.00
| Professional | | $213.80 | $251.19 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $295.12 / $316.23
| Professional | | $239.88 | $295.12 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $446.68 / $7,943.28
| Professional | | $346.74 | $446.68 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $269.15 / $338.84
| Professional | | $251.19 | $269.15 | $338.84 |
- 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
- $257.04 / $309.03 / $398.11
| Professional | | $257.04 | $309.03 | $398.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $346.74 / $3,548.13
| Professional | | $43.65 | $346.74 | $3,548.13 |