- 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
- $1,122.02 / $1,202.26 / $1,445.44
| Professional | | $1,122.02 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $1,380.38
| Professional | | $1,096.48 | $1,348.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $2,089.30
| Professional | | $1,548.82 | $1,698.24 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,174.90 / $1,479.11
| Professional | | $1,071.52 | $1,174.90 | $1,479.11 |
- 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
- $1,096.48 / $1,348.96 / $1,778.28
| Professional | | $1,096.48 | $1,348.96 | $1,778.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $1,148.15 / $1,778.28
| Professional | | $29.51 | $1,148.15 | $1,778.28 |