- 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
- $1,000.00 / $1,122.02 / $1,548.82
| Professional | | $1,000.00 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,548.82
| Professional | | $1,096.48 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $7,762.47
| Professional | | $1,479.11 | $1,737.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $1,584.89
| Professional | | $1,096.48 | $1,258.93 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $1,778.28
| Professional | | $870.96 | $1,288.25 | $1,778.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $9,549.93 / $11,748.98
| Professional | | $1,000.00 | $9,549.93 | $11,748.98 |