- 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
- $1,331.72 / $1,381.58 / $1,381.58
| Professional | | $1,331.72 | $1,381.58 | $1,381.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.13 / $1,579.83 / $1,579.83
| Professional | | $1,285.13 | $1,579.83 | $1,579.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.19 / $2,046.16 / $2,414.46
| Professional | | $1,821.19 | $2,046.16 | $2,414.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.25 / $1,516.63 / $1,769.40
| Professional | | $1,390.25 | $1,516.63 | $1,769.40 |
- 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
- $1,289.14 / $1,587.23 / $2,070.92
| Professional | | $1,289.14 | $1,587.23 | $2,070.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,302.43 / $2,064.01
| Professional | | $29.27 | $1,302.43 | $2,064.01 |