- 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
- $416.87 / $467.74 / $676.08
| Professional | | $416.87 | $467.74 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $575.44 / $1,819.70
| Professional | | $467.74 | $575.44 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $794.33
| Professional | | $602.56 | $676.08 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $616.60
| Professional | | $407.38 | $489.78 | $616.60 |
- 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
- $398.11 / $575.44 / $758.58
| Professional | | $398.11 | $575.44 | $758.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $478.63 / $776.25
| Professional | | $29.51 | $478.63 | $776.25 |