- 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
- $812.83 / $933.25 / $1,318.26
| Professional | | $812.83 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $1,318.26
| Professional | | $933.25 | $1,096.48 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $1,659.59
| Professional | | $1,258.93 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,318.26
| Professional | | $933.25 | $1,071.52 | $1,318.26 |
- 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
- $741.31 / $1,148.15 / $1,513.56
| Professional | | $741.31 | $1,148.15 | $1,513.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,235.94 / $6,165.95
| Professional | | $1,096.48 | $3,235.94 | $6,165.95 |