- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,047.13
| Professional | | $645.65 | $758.58 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $870.96
| Professional | | $741.31 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $7,943.28
| Professional | | $933.25 | $1,230.27 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $724.44 / $851.14
| Professional | | $660.69 | $724.44 | $851.14 |
- 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
- $741.31 / $831.76 / $1,122.02
| Professional | | $741.31 | $831.76 | $1,122.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $3,235.94 / $6,165.95
| Professional | | $831.76 | $3,235.94 | $6,165.95 |