- 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
- $724.44 / $794.33 / $1,122.02
| Professional | | $724.44 | $794.33 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $1,122.02
| Professional | | $794.33 | $912.01 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $17,378.01
| Professional | | $1,096.48 | $1,096.48 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,148.15
| Professional | | $812.83 | $912.01 | $1,148.15 |
- 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
- $630.96 / $933.25 / $1,288.25
| Professional | | $630.96 | $933.25 | $1,288.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $4,073.80 / $7,943.28
| Professional | | $933.25 | $4,073.80 | $7,943.28 |