- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $1,479.11
| Professional | | $977.24 | $1,096.48 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $1,445.44
| Professional | | $1,023.29 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,513.56 / $1,862.09
| Professional | | $1,412.54 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,479.11
| Professional | | $1,047.13 | $1,174.90 | $1,479.11 |
- 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
- $831.76 / $1,258.93 / $1,698.24
| Professional | | $831.76 | $1,258.93 | $1,698.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,073.80 / $7,943.28
| Professional | | $1,122.02 | $4,073.80 | $7,943.28 |