- 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
- $1,426.77 / $1,525.31 / $1,525.31
| Professional | | $1,426.77 | $1,525.31 | $1,525.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.48 / $1,977.48 / $2,005.63
| Professional | | $1,977.48 | $1,977.48 | $2,005.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.52 / $2,374.30 / $2,935.24
| Professional | | $2,169.52 | $2,374.30 | $2,935.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.95 / $1,925.40 / $2,246.30
| Professional | | $1,764.95 | $1,925.40 | $2,246.30 |
- 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
- $1,636.59 / $2,005.63 / $2,677.46
| Professional | | $1,636.59 | $2,005.63 | $2,677.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,773.65 / $2,568.39
| Professional | | $29.27 | $1,773.65 | $2,568.39 |