- 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
- $1,988.72 / $1,988.72 / $1,988.72
| Professional | | $1,988.72 | $1,988.72 | $1,988.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.16 / $2,201.35 / $2,641.62
| Professional | | $1,710.16 | $2,201.35 | $2,641.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,322.94 / $3,733.42 / $4,293.43
| Professional | | $3,322.94 | $3,733.42 | $4,293.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.19 / $2,113.30 / $2,465.51
| Professional | | $1,937.19 | $2,113.30 | $2,465.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.30 / $2,321.62 / $2,830.94
| Professional | | $1,796.30 | $2,321.62 | $2,830.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,122.77 / $2,702.13
| Professional | | $29.27 | $2,122.77 | $2,702.13 |