- 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
- $501.19 / $645.65 / $1,905.46
| Professional | | $501.19 | $645.65 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $870.96
| Professional | | $707.95 | $707.95 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $7,585.78
| Professional | | $933.25 | $1,174.90 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $741.31 / $870.96
| Professional | | $691.83 | $741.31 | $870.96 |
- 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
- $537.03 / $812.83 / $1,071.52
| Professional | | $537.03 | $812.83 | $1,071.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $3,235.94 / $6,165.95
| Professional | | $794.33 | $3,235.94 | $6,165.95 |