- 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
- $1,369.74 / $1,369.74 / $1,369.74
| Professional | | $1,369.74 | $1,369.74 | $1,369.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.17 / $1,757.17 / $2,750.68
| Professional | | $1,757.17 | $1,757.17 | $2,750.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.19 / $2,523.89 / $3,120.16
| Professional | | $2,306.19 | $2,523.89 | $3,120.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.59 / $2,640.65 / $3,080.76
| Professional | | $2,420.59 | $2,640.65 | $3,080.76 |
- 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
- $1,667.78 / $2,750.68 / $3,630.20
| Professional | | $1,667.78 | $2,750.68 | $3,630.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,313.34 / $3,053.61
| Professional | | $29.27 | $2,313.34 | $3,053.61 |