- 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
- $1,341.60 / $1,445.77 / $2,153.81
| Professional | | $1,341.60 | $1,445.77 | $2,153.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.13 / $1,737.03 / $1,771.93
| Professional | | $1,443.13 | $1,737.03 | $1,771.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.95 / $2,131.27 / $2,514.90
| Professional | | $1,896.95 | $2,131.27 | $2,514.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.58 / $1,667.54 / $1,945.47
| Professional | | $1,528.58 | $1,667.54 | $1,945.47 |
- 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
- $1,417.41 / $1,737.03 / $2,213.88
| Professional | | $1,417.41 | $1,737.03 | $2,213.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,485.15 / $1,887.80
| Professional | | $29.27 | $1,485.15 | $1,887.80 |