- 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
- $1,469.66 / $1,469.66 / $1,469.66
| Professional | | $1,469.66 | $1,469.66 | $1,469.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.53 / $1,590.53 / $1,911.45
| Professional | | $1,590.53 | $1,590.53 | $1,911.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.83 / $2,221.42 / $2,746.25
| Professional | | $2,029.83 | $2,221.42 | $2,746.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.66 / $1,526.90 / $1,781.39
| Professional | | $1,399.66 | $1,526.90 | $1,781.39 |
- 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
- $1,590.53 / $1,670.88 / $2,150.28
| Professional | | $1,590.53 | $1,670.88 | $2,150.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,643.28 / $1,876.58
| Professional | | $29.27 | $1,643.28 | $1,876.58 |