- 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
- $1,407.58 / $1,407.58 / $1,407.58
| Professional | | $1,407.58 | $1,407.58 | $1,407.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.35 / $1,486.35 / $1,817.97
| Professional | | $1,486.35 | $1,486.35 | $1,817.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,795.05 / $1,964.48 / $2,428.59
| Professional | | $1,795.05 | $1,964.48 | $2,428.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.99 / $1,426.90 / $1,664.71
| Professional | | $1,307.99 | $1,426.90 | $1,664.71 |
- 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
- $1,212.85 / $1,552.80 / $2,000.01
| Professional | | $1,212.85 | $1,552.80 | $2,000.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,618.17 / $2,411.29
| Professional | | $29.27 | $1,618.17 | $2,411.29 |