- 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
- $660.69 / $724.44 / $1,096.48
| Professional | | $660.69 | $724.44 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,096.48
| Professional | | $776.25 | $851.14 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,412.54
| Professional | | $1,047.13 | $1,148.15 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $1,174.90
| Professional | | $831.76 | $954.99 | $1,174.90 |
- 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
- $562.34 / $870.96 / $1,202.26
| Professional | | $562.34 | $870.96 | $1,202.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $4,073.80 / $7,943.28
| Professional | | $870.96 | $4,073.80 | $7,943.28 |