- 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
- $1,447.73 / $1,447.73 / $1,447.73
| Professional | | $1,447.73 | $1,447.73 | $1,447.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.41 / $1,644.41 / $1,880.69
| Professional | | $1,644.41 | $1,644.41 | $1,880.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.50 / $2,148.84 / $2,656.50
| Professional | | $1,963.50 | $2,148.84 | $2,656.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.08 / $1,578.64 / $1,841.74
| Professional | | $1,447.08 | $1,578.64 | $1,841.74 |
- 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
- $1,341.84 / $1,723.93 / $2,229.84
| Professional | | $1,341.84 | $1,723.93 | $2,229.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,782.37 / $2,619.65
| Professional | | $29.27 | $1,782.37 | $2,619.65 |