- 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
- $1,459.70 / $1,459.70 / $1,459.70
| Professional | | $1,459.70 | $1,459.70 | $1,459.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.04 / $1,818.04 / $1,902.62
| Professional | | $1,818.04 | $1,818.04 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.12 / $2,331.17 / $2,881.92
| Professional | | $2,130.12 | $2,331.17 | $2,881.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.87 / $1,745.32 / $2,036.20
| Professional | | $1,599.87 | $1,745.32 | $2,036.20 |
- 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
- $1,483.52 / $1,863.73 / $2,422.04
| Professional | | $1,483.52 | $1,863.73 | $2,422.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,805.18 / $2,650.08
| Professional | | $29.27 | $1,805.18 | $2,650.08 |