- 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
- $1,326.99 / $1,326.99 / $1,326.99
| Professional | | $1,326.99 | $1,326.99 | $1,326.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.80 / $1,599.80 / $1,716.83
| Professional | | $1,599.80 | $1,599.80 | $1,716.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.32 / $2,028.26 / $2,507.44
| Professional | | $1,853.32 | $2,028.26 | $2,507.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.82 / $1,535.81 / $1,791.78
| Professional | | $1,407.82 | $1,535.81 | $1,791.78 |
- 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
- $1,305.44 / $1,628.16 / $2,120.90
| Professional | | $1,305.44 | $1,628.16 | $2,120.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,635.21 / $2,198.80
| Professional | | $29.27 | $1,635.21 | $2,198.80 |