- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $4,466.84
| Facility | | $1,778.28 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,949.84
| Professional | | $660.69 | $851.14 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,202.26
| Professional | | $977.24 | $977.24 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $7,943.28
| Professional | | $1,318.26 | $1,584.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,288.25
| Professional | | $794.33 | $1,096.48 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,513.56
| Professional | | $724.44 | $1,023.29 | $1,513.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,691.53 / $6,165.95
| Professional | | $851.14 | $2,691.53 | $6,165.95 |