- 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
- $1,446.64 / $1,446.64 / $1,446.64
| Professional | | $1,446.64 | $1,446.64 | $1,446.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.03 / $1,562.03 / $1,943.90
| Professional | | $1,562.03 | $1,562.03 | $1,943.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.21 / $2,451.78 / $2,952.41
| Professional | | $2,182.21 | $2,451.78 | $2,952.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.58 / $1,499.54 / $1,749.47
| Professional | | $1,374.58 | $1,499.54 | $1,749.47 |
- 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
- $1,274.60 / $1,632.09 / $2,108.39
| Professional | | $1,274.60 | $1,632.09 | $2,108.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,162.39 / $1,736.75
| Professional | | $218.80 | $1,162.39 | $1,736.75 |