- 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
- $457.09 / $776.25 / $1,348.96
| Professional | | $457.09 | $776.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,348.96
| Professional | | $758.58 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,258.93
| Professional | | $831.76 | $1,000.00 | $1,258.93 |
- 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
- $281.84 / $794.33 / $1,288.25
| Professional | | $281.84 | $794.33 | $1,288.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $9,120.11 / $9,549.93
| Professional | | $7,943.28 | $9,120.11 | $9,549.93 |