- 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
- $1,249.01 / $1,336.27 / $1,336.27
| Professional | | $1,249.01 | $1,336.27 | $1,336.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.11 / $1,631.11 / $1,727.45
| Professional | | $1,631.11 | $1,631.11 | $1,727.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.58 / $2,066.85 / $2,555.14
| Professional | | $1,888.58 | $2,066.85 | $2,555.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.38 / $1,565.87 / $1,826.85
| Professional | | $1,435.38 | $1,565.87 | $1,826.85 |
- 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
- $1,330.99 / $1,653.42 / $2,158.34
| Professional | | $1,330.99 | $1,653.42 | $2,158.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,635.28 / $2,391.59
| Professional | | $29.27 | $1,635.28 | $2,391.59 |