- 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
- $331.13 / $389.05 / $562.34
| Professional | | $331.13 | $389.05 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $436.52 / $575.44
| Professional | | $407.38 | $436.52 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $645.65 / $2,630.27
| Professional | | $562.34 | $645.65 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $512.86 / $660.69
| Professional | | $416.87 | $512.86 | $660.69 |
- 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
- $302.00 / $436.52 / $575.44
| Professional | | $302.00 | $436.52 | $575.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $416.87 / $562.34
| Professional | | $70.79 | $416.87 | $562.34 |