- 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
- $1,229.99 / $1,229.99 / $1,229.99
| Professional | | $1,229.99 | $1,229.99 | $1,229.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.81 / $1,509.81 / $1,584.19
| Professional | | $1,509.81 | $1,509.81 | $1,584.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.15 / $1,891.28 / $2,338.09
| Professional | | $1,728.15 | $1,891.28 | $2,338.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.64 / $1,449.42 / $1,690.99
| Professional | | $1,328.64 | $1,449.42 | $1,690.99 |
- 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
- $1,232.01 / $1,519.30 / $1,987.19
| Professional | | $1,232.01 | $1,519.30 | $1,987.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,535.91 / $2,243.03
| Professional | | $29.27 | $1,535.91 | $2,243.03 |