- 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
- $1,375.14 / $1,375.14 / $1,375.14
| Professional | | $1,375.14 | $1,375.14 | $1,375.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.06 / $1,695.06 / $1,730.28
| Professional | | $1,695.06 | $1,695.06 | $1,730.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.70 / $2,028.67 / $2,507.94
| Professional | | $1,853.70 | $2,028.67 | $2,507.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.66 / $1,627.26 / $1,898.47
| Professional | | $1,491.66 | $1,627.26 | $1,898.47 |
- 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
- $1,383.17 / $1,695.06 / $2,249.81
| Professional | | $1,383.17 | $1,695.06 | $2,249.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,502.42 / $2,183.38
| Professional | | $29.27 | $1,502.42 | $2,183.38 |