- 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
- $1,623.02 / $1,623.02 / $1,623.02
| Professional | | $1,623.02 | $1,623.02 | $1,623.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.01 / $1,781.01 / $2,112.52
| Professional | | $1,781.01 | $1,781.01 | $2,112.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.58 / $2,442.23 / $3,019.20
| Professional | | $2,231.58 | $2,442.23 | $3,019.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.29 / $1,709.77 / $1,994.73
| Professional | | $1,567.29 | $1,709.77 | $1,994.73 |
- 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
- $1,453.31 / $1,869.02 / $2,404.41
| Professional | | $1,453.31 | $1,869.02 | $2,404.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,979.24 / $2,961.47
| Professional | | $29.27 | $1,979.24 | $2,961.47 |