- 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
- $407.38 / $776.25 / $831.76
| Professional | | $407.38 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $776.25
| Professional | | $660.69 | $660.69 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $912.01 / $1,096.48
| Professional | | $851.14 | $912.01 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $602.56 / $707.95
| Professional | | $549.54 | $602.56 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,000.00
| Professional | | $537.03 | $758.58 | $1,000.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $724.44 / $1,071.52
| Professional | | $29.51 | $724.44 | $1,071.52 |