- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $8,511.38
| Facility | | $2,818.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $933.25 / $1,258.93
| Professional | | $851.14 | $933.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,230.27
| Professional | | $954.99 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,737.80
| Professional | | $1,318.26 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,122.02 / $1,412.54
| Professional | | $1,023.29 | $1,122.02 | $1,412.54 |
- 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
- $1,023.29 / $1,174.90 / $1,548.82
| Professional | | $1,023.29 | $1,174.90 | $1,548.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $891.25 / $1,513.56
| Professional | | $29.51 | $891.25 | $1,513.56 |