- 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
- $288.40 / $1,288.25 / $2,344.23
| Professional | | $288.40 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,862.09 / $2,238.72
| Professional | | $363.08 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $602.56 / $2,344.23
| Professional | | $436.52 | $602.56 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,513.56 / $1,905.46
| Professional | | $263.03 | $1,513.56 | $1,905.46 |
- 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
- $346.74 / $1,513.56 / $2,818.38
| Professional | | $346.74 | $1,513.56 | $2,818.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $363.08 / $2,570.40
| Professional | | $281.84 | $363.08 | $2,570.40 |