- 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
- $645.65 / $954.99 / $1,318.26
| Professional | | $645.65 | $954.99 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,096.48
| Professional | | $831.76 | $977.24 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $7,943.28
| Professional | | $1,230.27 | $1,584.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $954.99 / $1,202.26
| Professional | | $891.25 | $954.99 | $1,202.26 |
- 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
- $912.01 / $1,023.29 / $1,380.38
| Professional | | $912.01 | $1,023.29 | $1,380.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,235.94 / $6,165.95
| Professional | | $1,096.48 | $3,235.94 | $6,165.95 |