- 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
- $1,051.21 / $1,051.21 / $1,051.21
| Professional | | $1,051.21 | $1,051.21 | $1,051.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.06 / $1,344.06 / $1,362.16
| Professional | | $1,344.06 | $1,344.06 | $1,362.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.97 / $1,624.05 / $2,007.73
| Professional | | $1,483.97 | $1,624.05 | $2,007.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.70 / $1,307.68 / $1,525.62
| Professional | | $1,198.70 | $1,307.68 | $1,525.62 |
- 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
- $1,111.52 / $1,362.16 / $1,725.42
| Professional | | $1,111.52 | $1,362.16 | $1,725.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,329.79 / $1,715.33
| Professional | | $29.27 | $1,329.79 | $1,715.33 |