- 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
- $1,548.39 / $1,548.39 / $1,548.39
| Professional | | $1,548.39 | $1,548.39 | $1,548.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.03 / $1,923.24 / $2,307.89
| Professional | | $1,500.03 | $1,923.24 | $2,307.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.03 / $2,228.21 / $2,630.67
| Professional | | $2,036.03 | $2,228.21 | $2,630.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.45 / $1,846.31 / $2,154.03
| Professional | | $1,692.45 | $1,846.31 | $2,154.03 |
- 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
- $1,559.24 / $1,923.24 / $2,458.07
| Professional | | $1,559.24 | $1,923.24 | $2,458.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,457.89 / $2,094.94
| Professional | | $29.27 | $1,457.89 | $2,094.94 |