- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $11,220.18 / $11,220.18
| Facility | | $2,818.38 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,659.59 / $2,630.27
| Professional | | $446.68 | $1,659.59 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $2,187.76 / $2,754.23
| Professional | | $562.34 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $912.01 / $9,549.93
| Professional | | $707.95 | $912.01 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,778.28 / $2,238.72
| Professional | | $398.11 | $1,778.28 | $2,238.72 |
- 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
- $524.81 / $1,778.28 / $3,388.44
| Professional | | $524.81 | $1,778.28 | $3,388.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $549.54 / $3,162.28
| Professional | | $363.08 | $549.54 | $3,162.28 |