- 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
- $660.69 / $776.25 / $954.99
| Professional | | $660.69 | $776.25 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $851.14
| Professional | | $676.08 | $794.33 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $6,606.93 / $12,589.25
| Professional | | $1,000.00 | $6,606.93 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $933.25
| Professional | | $691.83 | $758.58 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,096.48
| Professional | | $691.83 | $870.96 | $1,096.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $602.56 / $6,918.31
| Professional | | $29.51 | $602.56 | $6,918.31 |