- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $912.01 / $1,819.70
| Professional | | $263.03 | $912.01 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $660.69 / $2,754.23
| Professional | | $363.08 | $660.69 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $537.03 / $11,220.18
| Professional | | $446.68 | $537.03 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,380.38 / $1,737.80
| Professional | | $263.03 | $1,380.38 | $1,737.80 |
- 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
- $354.81 / $1,148.15 / $2,137.96
| Professional | | $354.81 | $1,148.15 | $2,137.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $1,819.70
| Professional | | $239.88 | $363.08 | $1,819.70 |