- 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
- $1,174.90 / $1,348.96 / $1,995.26
| Professional | | $1,174.90 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $5,011.87
| Professional | | $1,318.26 | $1,621.81 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,344.23
| Professional | | $1,737.80 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $1,819.70
| Professional | | $1,230.27 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,187.76
| Professional | | $1,202.26 | $1,659.59 | $2,187.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,202.26 / $1,949.84
| Professional | | $29.51 | $1,202.26 | $1,949.84 |