- 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
- $562.34 / $616.60 / $870.96
| Professional | | $562.34 | $616.60 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $707.95 / $870.96
| Professional | | $616.60 | $707.95 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $1,096.48
| Professional | | $812.83 | $891.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $912.01
| Professional | | $645.65 | $724.44 | $912.01 |
- 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
- $478.63 / $645.65 / $1,000.00
| Professional | | $478.63 | $645.65 | $1,000.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,691.53 / $6,165.95
| Professional | | $707.95 | $2,691.53 | $6,165.95 |