- 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
- $1,395.10 / $1,489.65 / $1,489.65
| Professional | | $1,395.10 | $1,489.65 | $1,489.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.25 / $1,785.25 / $1,924.56
| Professional | | $1,785.25 | $1,785.25 | $1,924.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.53 / $2,282.38 / $2,821.59
| Professional | | $2,085.53 | $2,282.38 | $2,821.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.02 / $1,713.84 / $1,999.48
| Professional | | $1,571.02 | $1,713.84 | $1,999.48 |
- 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
- $1,456.76 / $1,830.36 / $2,381.15
| Professional | | $1,456.76 | $1,830.36 | $2,381.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,317.93 / $1,969.15
| Professional | | $29.27 | $1,317.93 | $1,969.15 |