- 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
- $524.81 / $616.60 / $912.01
| Professional | | $524.81 | $616.60 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $2,344.23
| Professional | | $537.03 | $758.58 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $1,071.52
| Professional | | $794.33 | $891.25 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $707.95 / $870.96
| Professional | | $588.84 | $707.95 | $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
- $549.54 / $741.31 / $1,047.13
| Professional | | $549.54 | $741.31 | $1,047.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $691.83 / $1,096.48
| Professional | | $29.51 | $691.83 | $1,096.48 |