- 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
- $223.87 / $446.68 / $1,096.48
| Professional | | $223.87 | $446.68 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $831.76 / $2,041.74
| Professional | | $281.84 | $831.76 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $537.03 / $1,096.48
| Professional | | $457.09 | $537.03 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $1,000.00 / $1,288.25
| Professional | | $229.09 | $1,000.00 | $1,288.25 |
- 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
- $245.47 / $691.83 / $1,202.26
| Professional | | $245.47 | $691.83 | $1,202.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $2,951.21 / $5,370.32
| Professional | | $316.23 | $2,951.21 | $5,370.32 |