- 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
- $630.96 / $691.83 / $954.99
| Professional | | $630.96 | $691.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $954.99
| Professional | | $676.08 | $794.33 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $1,202.26
| Professional | | $912.01 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $977.24
| Professional | | $691.83 | $794.33 | $977.24 |
- 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
- $537.03 / $794.33 / $1,096.48
| Professional | | $537.03 | $794.33 | $1,096.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,691.53 / $6,165.95
| Professional | | $794.33 | $2,691.53 | $6,165.95 |