- 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
- $436.52 / $776.25 / $851.14
| Professional | | $436.52 | $776.25 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $812.83
| Professional | | $776.25 | $776.25 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $977.24 / $1,174.90
| Professional | | $912.01 | $977.24 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $870.96
| Professional | | $691.83 | $758.58 | $870.96 |
- 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
- $630.96 / $776.25 / $1,023.29
| Professional | | $630.96 | $776.25 | $1,023.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $776.25 / $851.14
| Professional | | $107.15 | $776.25 | $851.14 |