- 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
- $407.38 / $851.14 / $2,691.53
| Professional | | $407.38 | $851.14 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $2,137.96 / $2,630.27
| Professional | | $512.86 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $9,549.93
| Professional | | $630.96 | $851.14 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,778.28 / $2,187.76
| Professional | | $371.54 | $1,778.28 | $2,187.76 |
- 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
- $489.78 / $1,737.80 / $3,311.31
| Professional | | $489.78 | $1,737.80 | $3,311.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $512.86 / $3,019.95
| Professional | | $338.84 | $512.86 | $3,019.95 |