- 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
- $363.08 / $467.74 / $1,148.15
| Professional | | $363.08 | $467.74 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,000.00
| Professional | | $776.25 | $851.14 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $616.60 / $1,023.29
| Professional | | $331.13 | $616.60 | $1,023.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,715.35 / $6,165.95
| Professional | | $1,096.48 | $3,715.35 | $6,165.95 |