- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,258.93
| Professional | | $562.34 | $741.31 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $954.99
| Professional | | $831.76 | $831.76 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $7,413.10
| Professional | | $1,000.00 | $1,202.26 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,047.13
| Professional | | $588.84 | $870.96 | $1,047.13 |
- 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
- $616.60 / $831.76 / $1,230.27
| Professional | | $616.60 | $831.76 | $1,230.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $2,630.27 / $6,606.93
| Professional | | $660.69 | $2,630.27 | $6,606.93 |