- 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
- $1,303.54 / $1,303.54 / $1,303.54
| Professional | | $1,303.54 | $1,303.54 | $1,303.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.26 / $1,475.26 / $1,715.68
| Professional | | $1,475.26 | $1,475.26 | $1,715.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.28 / $1,964.74 / $2,428.90
| Professional | | $1,795.28 | $1,964.74 | $2,428.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.23 / $1,416.25 / $1,652.29
| Professional | | $1,298.23 | $1,416.25 | $1,652.29 |
- 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
- $1,203.81 / $1,498.31 / $1,960.58
| Professional | | $1,203.81 | $1,498.31 | $1,960.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,489.27 / $2,114.89
| Professional | | $29.27 | $1,489.27 | $2,114.89 |