- 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
- $338.84 / $1,148.15 / $2,290.87
| Professional | | $338.84 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,905.46 / $1,949.84
| Professional | | $446.68 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $2,398.83 / $9,549.93
| Professional | | $549.54 | $2,398.83 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,548.82 / $1,949.84
| Professional | | $323.59 | $1,548.82 | $1,949.84 |
- 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
- $436.52 / $1,584.89 / $2,454.71
| Professional | | $436.52 | $1,584.89 | $2,454.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $2,089.30 / $7,413.10
| Professional | | $295.12 | $2,089.30 | $7,413.10 |