- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.14 / $1,454.62 / $1,454.62
| Professional | | $1,360.14 | $1,454.62 | $1,454.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.06 / $1,788.06 / $1,882.94
| Professional | | $1,788.06 | $1,788.06 | $1,882.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.46 / $2,254.94 / $2,787.68
| Professional | | $2,060.46 | $2,254.94 | $2,787.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.50 / $1,716.54 / $2,002.63
| Professional | | $1,573.50 | $1,716.54 | $2,002.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.06 / $1,788.06 / $2,363.90
| Professional | | $1,459.06 | $1,788.06 | $2,363.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,786.78 / $2,572.77
| Professional | | $29.27 | $1,786.78 | $2,572.77 |