- 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
- $1,486.40 / $1,486.40 / $1,486.40
| Professional | | $1,486.40 | $1,486.40 | $1,486.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.95 / $1,809.95 / $1,925.29
| Professional | | $1,809.95 | $1,809.95 | $1,925.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.81 / $2,296.92 / $2,839.57
| Professional | | $2,098.81 | $2,296.92 | $2,839.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.76 / $1,737.55 / $2,027.14
| Professional | | $1,592.76 | $1,737.55 | $2,027.14 |
- 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
- $1,476.92 / $1,840.49 / $2,399.42
| Professional | | $1,476.92 | $1,840.49 | $2,399.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,849.50 / $2,726.70
| Professional | | $29.27 | $1,849.50 | $2,726.70 |