- 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
- $691.83 / $776.25 / $1,348.96
| Professional | | $691.83 | $776.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,047.13
| Professional | | $741.31 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,888.44 / $8,317.64
| Professional | | $1,096.48 | $5,888.44 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $1,096.48
| Professional | | $758.58 | $870.96 | $1,096.48 |
- 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
- $588.84 / $870.96 / $1,202.26
| Professional | | $588.84 | $870.96 | $1,202.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,235.94 / $6,165.95
| Professional | | $1,023.29 | $3,235.94 | $6,165.95 |