- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,818.38 / $3,890.45
| Facility | | $1,479.11 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $3,801.89
| Professional | | $676.08 | $794.33 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $870.96 / $1,122.02
| Professional | | $794.33 | $870.96 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $7,762.47
| Professional | | $1,071.52 | $1,258.93 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $1,148.15
| Professional | | $812.83 | $933.25 | $1,148.15 |
- 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
- $602.56 / $891.25 / $1,230.27
| Professional | | $602.56 | $891.25 | $1,230.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,089.30 / $5,370.32
| Professional | | $870.96 | $2,089.30 | $5,370.32 |