- 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
- $223.87 / $275.42 / $316.23
| Professional | | $223.87 | $275.42 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $323.59 / $338.84
| Professional | | $275.42 | $323.59 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $426.58 / $512.86
| Professional | | $389.05 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $275.42 / $346.74
| Professional | | $251.19 | $275.42 | $346.74 |
- 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
- $263.03 / $346.74 / $436.52
| Professional | | $263.03 | $346.74 | $436.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $239.88 / $501.19
| Professional | | $29.51 | $239.88 | $501.19 |