- 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
- $295.12 / $398.11 / $630.96
| Professional | | $295.12 | $398.11 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $588.84
| Professional | | $489.78 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $812.83
| Professional | | $602.56 | $724.44 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $616.60
| Professional | | $354.81 | $524.81 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $562.34 / $776.25
| Professional | | $354.81 | $562.34 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $416.87 / $549.54
| Professional | | $79.43 | $416.87 | $549.54 |