- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,623.41 / $6,025.60
| Facility | | $1,862.09 | $5,623.41 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $5,495.41
| Professional | | $977.24 | $1,258.93 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,479.11
| Professional | | $1,047.13 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $14,125.38
| Professional | | $1,412.54 | $1,659.59 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,479.11
| Professional | | $1,047.13 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $1,698.24
| Professional | | $851.14 | $1,318.26 | $1,698.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,677.35 / $9,332.54
| Professional | | $1,445.44 | $4,677.35 | $9,332.54 |