- 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
- $1,453.07 / $1,453.07 / $1,453.07
| Professional | | $1,453.07 | $1,453.07 | $1,453.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.55 / $1,513.55 / $1,861.18
| Professional | | $1,513.55 | $1,513.55 | $1,861.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.92 / $2,165.71 / $2,677.36
| Professional | | $1,978.92 | $2,165.71 | $2,677.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.92 / $1,453.01 / $1,695.18
| Professional | | $1,331.92 | $1,453.01 | $1,695.18 |
- 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
- $1,235.06 / $1,744.21 / $2,261.31
| Professional | | $1,235.06 | $1,744.21 | $2,261.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,639.97 / $2,467.98
| Professional | | $29.27 | $1,639.97 | $2,467.98 |