- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,380.38
| Professional | | $891.25 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,348.96
| Professional | | $954.99 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $1,698.24
| Professional | | $1,288.25 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,380.38
| Professional | | $954.99 | $1,096.48 | $1,380.38 |
- 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
- $776.25 / $1,174.90 / $1,584.89
| Professional | | $776.25 | $1,174.90 | $1,584.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,023.29 / $1,318.26
| Professional | | $29.51 | $1,023.29 | $1,318.26 |