- 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
- $1,730.65 / $1,730.65 / $1,730.65
| Professional | | $1,730.65 | $1,730.65 | $1,730.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.21 / $1,841.21 / $2,228.50
| Professional | | $1,841.21 | $1,841.21 | $2,228.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.91 / $2,589.23 / $3,200.93
| Professional | | $2,365.91 | $2,589.23 | $3,200.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.27 / $1,767.56 / $2,062.16
| Professional | | $1,620.27 | $1,767.56 | $2,062.16 |
- 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
- $1,502.43 / $1,932.19 / $2,485.79
| Professional | | $1,502.43 | $1,932.19 | $2,485.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,948.49 / $2,921.94
| Professional | | $29.27 | $1,948.49 | $2,921.94 |