- 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
- $758.58 / $891.25 / $1,258.93
| Professional | | $758.58 | $891.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $1,258.93
| Professional | | $891.25 | $977.24 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $7,943.28
| Professional | | $1,230.27 | $1,412.54 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,348.96
| Professional | | $933.25 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,380.38
| Professional | | $660.69 | $1,000.00 | $1,380.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,691.53 / $6,165.95
| Professional | | $1,000.00 | $2,691.53 | $6,165.95 |