- 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
- $489.78 / $602.56 / $1,023.29
| Professional | | $489.78 | $602.56 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $933.25
| Professional | | $758.58 | $758.58 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $4,897.79
| Professional | | $1,000.00 | $1,230.27 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,071.52
| Professional | | $630.96 | $891.25 | $1,071.52 |
- 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
- $524.81 / $812.83 / $1,174.90
| Professional | | $524.81 | $812.83 | $1,174.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,041.74 / $5,370.32
| Professional | | $645.65 | $2,041.74 | $5,370.32 |