- 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
- $1,447.09 / $1,447.09 / $1,447.09
| Professional | | $1,447.09 | $1,447.09 | $1,447.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.40 / $1,620.40 / $1,893.17
| Professional | | $1,620.40 | $1,620.40 | $1,893.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.67 / $2,311.00 / $2,856.98
| Professional | | $2,111.67 | $2,311.00 | $2,856.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.95 / $1,555.58 / $1,814.85
| Professional | | $1,425.95 | $1,555.58 | $1,814.85 |
- 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
- $1,322.25 / $1,697.46 / $2,184.62
| Professional | | $1,322.25 | $1,697.46 | $2,184.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,672.64 / $2,685.06
| Professional | | $29.27 | $1,672.64 | $2,685.06 |