- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $954.99
| Professional | | $575.44 | $691.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,096.48
| Professional | | $660.69 | $851.14 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $4,365.16
| Professional | | $912.01 | $1,122.02 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,000.00
| Professional | | $602.56 | $776.25 | $1,000.00 |
- 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
- $446.68 / $724.44 / $1,096.48
| Professional | | $446.68 | $724.44 | $1,096.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $3,162.28 / $7,585.78
| Professional | | $691.83 | $3,162.28 | $7,585.78 |