- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $870.96 / $2,238.72
| Professional | | $295.12 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,318.26 / $1,862.09
| Professional | | $363.08 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $7,413.10
| Professional | | $549.54 | $676.08 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,737.80 / $2,187.76
| Professional | | $346.74 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,513.56 / $2,089.30
| Professional | | $380.19 | $1,513.56 | $2,089.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $2,630.27 / $6,165.95
| Professional | | $436.52 | $2,630.27 | $6,165.95 |