- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $6,918.31
| Facility | | $2,818.38 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $1,905.46
| Professional | | $1,122.02 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $4,786.30
| Professional | | $1,258.93 | $1,548.82 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $2,187.76
| Professional | | $1,659.59 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $1,737.80
| Professional | | $1,148.15 | $1,380.38 | $1,737.80 |
- 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
- $1,148.15 / $1,584.89 / $2,089.30
| Professional | | $1,148.15 | $1,584.89 | $2,089.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,148.15 / $1,862.09
| Professional | | $29.51 | $1,148.15 | $1,862.09 |