- 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
- $194.98 / $346.74 / $363.08
| Professional | | $194.98 | $346.74 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $436.52 / $524.81
| Professional | | $407.38 | $436.52 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $288.40 / $331.13
| Professional | | $263.03 | $288.40 | $331.13 |
- 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
- $269.15 / $338.84 / $436.52
| Professional | | $269.15 | $338.84 | $436.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $245.47 / $371.54
| Professional | | $29.51 | $245.47 | $371.54 |