- 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
- $501.19 / $912.01 / $1,000.00
| Professional | | $501.19 | $912.01 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $933.25
| Professional | | $870.96 | $870.96 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,148.15 / $1,380.38
| Professional | | $1,071.52 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $812.83 / $954.99
| Professional | | $741.31 | $812.83 | $954.99 |
- 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
- $724.44 / $933.25 / $1,202.26
| Professional | | $724.44 | $933.25 | $1,202.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $660.69 / $977.24
| Professional | | $123.03 | $660.69 | $977.24 |