- 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
- $316.23 / $977.24 / $1,819.70
| Professional | | $316.23 | $977.24 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,412.54 / $1,479.11
| Professional | | $398.11 | $1,412.54 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $660.69 / $1,737.80
| Professional | | $537.03 | $660.69 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,380.38 / $1,737.80
| Professional | | $346.74 | $1,380.38 | $1,737.80 |
- 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
- $371.54 / $1,202.26 / $1,659.59
| Professional | | $371.54 | $1,202.26 | $1,659.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $2,570.40 / $6,165.95
| Professional | | $436.52 | $2,570.40 | $6,165.95 |