- 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
- $288.40 / $446.68 / $741.31
| Professional | | $288.40 | $446.68 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $602.56
| Professional | | $512.86 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $602.56 / $4,677.35
| Professional | | $489.78 | $602.56 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $537.03 / $645.65
| Professional | | $302.00 | $537.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $524.81 / $776.25
| Professional | | $316.23 | $524.81 | $776.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $407.38 / $660.69
| Professional | | $83.18 | $407.38 | $660.69 |