- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $229.09 / $295.12
| Professional | | $194.98 | $229.09 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $257.04 / $281.84
| Professional | | $239.88 | $257.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $7,943.28
| Professional | | $1,023.29 | $1,318.26 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $245.47 / $302.00
| Professional | | $223.87 | $245.47 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $295.12 / $371.54
| Professional | | $229.09 | $295.12 | $371.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $204.17 / $436.52
| Professional | | $29.51 | $204.17 | $436.52 |