- 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
- $229.09 / $275.42 / $436.52
| Professional | | $229.09 | $275.42 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $323.59 / $416.87
| Professional | | $295.12 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $457.09 / $2,630.27
| Professional | | $398.11 | $457.09 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $426.58 / $537.03
| Professional | | $354.81 | $426.58 | $537.03 |
- 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
- $218.78 / $323.59 / $416.87
| Professional | | $218.78 | $323.59 | $416.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $323.59 / $407.38
| Professional | | $50.12 | $323.59 | $407.38 |