- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,943.28 / $8,511.38
| Facility | | $2,818.38 | $7,943.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,884.03
| Professional | | $1,202.26 | $1,548.82 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,513.56
| Professional | | $1,288.25 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $14,791.08
| Professional | | $1,905.46 | $2,454.71 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,445.44
| Professional | | $1,122.02 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $1,949.84
| Professional | | $1,288.25 | $1,513.56 | $1,949.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,677.35 / $9,772.37
| Professional | | $1,445.44 | $4,677.35 | $9,772.37 |