- 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
- $1,337.76 / $1,337.76 / $1,337.76
| Professional | | $1,337.76 | $1,337.76 | $1,337.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.76 / $1,731.26 / $2,077.52
| Professional | | $1,353.76 | $1,731.26 | $2,077.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.89 / $2,008.08 / $2,370.78
| Professional | | $1,834.89 | $2,008.08 | $2,370.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.51 / $1,662.01 / $1,939.01
| Professional | | $1,523.51 | $1,662.01 | $1,939.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.79 / $1,731.26 / $2,264.94
| Professional | | $1,329.79 | $1,731.26 | $2,264.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,253.89 / $1,976.42
| Professional | | $29.27 | $1,253.89 | $1,976.42 |