- 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
- $1,521.66 / $1,521.66 / $1,521.66
| Professional | | $1,521.66 | $1,521.66 | $1,521.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.98 / $1,805.98 / $1,976.72
| Professional | | $1,805.98 | $1,805.98 | $1,976.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.40 / $2,322.73 / $2,871.48
| Professional | | $2,122.40 | $2,322.73 | $2,871.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.26 / $1,733.74 / $2,022.69
| Professional | | $1,589.26 | $1,733.74 | $2,022.69 |
- 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
- $1,473.68 / $1,857.21 / $2,411.37
| Professional | | $1,473.68 | $1,857.21 | $2,411.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,853.63 / $2,157.40
| Professional | | $29.27 | $1,853.63 | $2,157.40 |