- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,162.28 / $8,511.38
| Facility | | $2,818.38 | $3,162.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,258.93
| Professional | | $630.96 | $891.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,047.13
| Professional | | $812.83 | $912.01 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $7,943.28
| Professional | | $1,148.15 | $1,479.11 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $954.99 / $1,174.90
| Professional | | $870.96 | $954.99 | $1,174.90 |
- 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
- $851.14 / $1,000.00 / $1,348.96
| Professional | | $851.14 | $1,000.00 | $1,348.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,623.41 / $11,220.18
| Professional | | $912.01 | $5,623.41 | $11,220.18 |