- 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
- $707.95 / $831.76 / $1,288.25
| Professional | | $707.95 | $831.76 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,174.90
| Professional | | $954.99 | $954.99 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,348.96 / $1,621.81
| Professional | | $1,230.27 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,023.29 / $1,202.26
| Professional | | $954.99 | $1,023.29 | $1,202.26 |
- 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
- $758.58 / $1,148.15 / $1,513.56
| Professional | | $758.58 | $1,148.15 | $1,513.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $831.76 / $1,096.48
| Professional | | $158.49 | $831.76 | $1,096.48 |