- 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
- $891.25 / $1,000.00 / $1,348.96
| Professional | | $891.25 | $1,000.00 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,348.96
| Professional | | $954.99 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $1,778.28
| Professional | | $1,348.96 | $1,479.11 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $1,348.96
| Professional | | $954.99 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $1,548.82
| Professional | | $776.25 | $1,230.27 | $1,548.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,235.94 / $6,165.95
| Professional | | $1,174.90 | $3,235.94 | $6,165.95 |