- 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
- $812.83 / $912.01 / $1,148.15
| Professional | | $812.83 | $912.01 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,122.02
| Professional | | $776.25 | $1,023.29 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,311.31 / $5,623.41
| Professional | | $1,230.27 | $3,311.31 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,096.48
| Professional | | $776.25 | $891.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,348.96
| Professional | | $660.69 | $1,023.29 | $1,348.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $4,073.80 / $7,943.28
| Professional | | $954.99 | $4,073.80 | $7,943.28 |