- 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
- $316.23 / $724.44 / $1,288.25
| Professional | | $316.23 | $724.44 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $912.01 / $1,288.25
| Professional | | $346.74 | $912.01 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $707.95 / $4,570.88
| Professional | | $575.44 | $707.95 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,047.13 / $1,318.26
| Professional | | $436.52 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $933.25 / $1,445.44
| Professional | | $389.05 | $933.25 | $1,445.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,570.40 / $6,165.95
| Professional | | $467.74 | $2,570.40 | $6,165.95 |