- 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
- $1,487.24 / $1,487.24 / $1,487.24
| Professional | | $1,487.24 | $1,487.24 | $1,487.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.25 / $1,796.25 / $1,934.70
| Professional | | $1,796.25 | $1,796.25 | $1,934.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.32 / $2,297.48 / $2,840.26
| Professional | | $2,099.32 | $2,297.48 | $2,840.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.70 / $1,724.40 / $2,011.80
| Professional | | $1,580.70 | $1,724.40 | $2,011.80 |
- 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
- $1,465.74 / $1,856.11 / $2,407.19
| Professional | | $1,465.74 | $1,856.11 | $2,407.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,850.05 / $2,684.91
| Professional | | $29.27 | $1,850.05 | $2,684.91 |