- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.08 / $1,273.08 / $1,273.08
| Facility | | $1,273.08 | $1,273.08 | $1,273.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.10 / $1,028.39 / $1,043.00
| Professional | | $779.10 | $1,028.39 | $1,043.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.08 / $1,273.08 / $1,273.08
| Facility | | $1,273.08 | $1,273.08 | $1,273.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.84 / $748.84 / $748.84
| Professional | | $748.84 | $748.84 | $748.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.47 / $1,044.47 / $1,232.47
| Professional | | $1,044.47 | $1,044.47 | $1,232.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.73 / $898.61 / $1,048.38
| Professional | | $823.73 | $898.61 | $1,048.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.85 / $858.47 / $1,123.28
| Professional | | $748.85 | $858.47 | $1,123.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.01 / $714.72 / $865.62
| Professional | | $61.01 | $714.72 | $865.62 |