- 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
- $645.65 / $1,047.13 / $1,258.93
| Professional | | $645.65 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $489.78 / $602.56
| Professional | | $457.09 | $489.78 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $436.52 / $501.19
| Professional | | $398.11 | $436.52 | $501.19 |
- 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
- $316.23 / $478.63 / $524.81
| Professional | | $316.23 | $478.63 | $524.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $398.11 / $436.52
| Professional | | $29.51 | $398.11 | $436.52 |