- 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
- $776.25 / $912.01 / $1,288.25
| Professional | | $776.25 | $912.01 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,023.29 / $1,288.25
| Professional | | $912.01 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $7,943.28
| Professional | | $1,258.93 | $1,445.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $1,380.38
| Professional | | $977.24 | $1,096.48 | $1,380.38 |
- 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
- $676.08 / $1,071.52 / $1,412.54
| Professional | | $676.08 | $1,071.52 | $1,412.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,691.53 / $6,165.95
| Professional | | $1,096.48 | $2,691.53 | $6,165.95 |