- 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
- $724.44 / $812.83 / $1,096.48
| Professional | | $724.44 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,096.48
| Professional | | $776.25 | $891.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $11,748.98
| Professional | | $1,047.13 | $1,230.27 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,096.48
| Professional | | $776.25 | $891.25 | $1,096.48 |
- 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
- $616.60 / $912.01 / $1,258.93
| Professional | | $616.60 | $912.01 | $1,258.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,691.53 / $6,165.95
| Professional | | $912.01 | $2,691.53 | $6,165.95 |