- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $724.44 / $1,584.89
| Professional | | $223.87 | $724.44 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $524.81 / $2,089.30
| Professional | | $275.42 | $524.81 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $6,025.60
| Professional | | $354.81 | $489.78 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,174.90 / $1,479.11
| Professional | | $204.17 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $933.25 / $1,862.09
| Professional | | $263.03 | $933.25 | $1,862.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $288.40 / $1,584.89
| Professional | | $186.21 | $288.40 | $1,584.89 |