- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $6,918.31 / $6,918.31
| Facility | | $2,137.96 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,737.80
| Professional | | $776.25 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,148.15
| Professional | | $1,000.00 | $1,000.00 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $7,943.28
| Professional | | $1,258.93 | $1,621.81 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $954.99 / $1,122.02
| Professional | | $870.96 | $954.99 | $1,122.02 |
- 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
- $977.24 / $1,122.02 / $1,479.11
| Professional | | $977.24 | $1,122.02 | $1,479.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,630.78 / $6,606.93
| Professional | | $1,096.48 | $3,630.78 | $6,606.93 |