- 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
- $707.95 / $1,548.82 / $1,659.59
| Professional | | $707.95 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,548.82
| Professional | | $1,047.13 | $1,047.13 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,888.44 / $8,317.64
| Professional | | $1,584.89 | $5,888.44 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $1,698.24
| Professional | | $1,348.96 | $1,445.44 | $1,698.24 |
- 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
- $1,096.48 / $1,445.44 / $1,995.26
| Professional | | $1,096.48 | $1,445.44 | $1,995.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,073.80 / $7,943.28
| Professional | | $1,348.96 | $4,073.80 | $7,943.28 |