- 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
- $1,493.46 / $1,565.76 / $1,565.76
| Professional | | $1,493.46 | $1,565.76 | $1,565.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.26 / $1,779.96 / $1,785.88
| Professional | | $1,439.26 | $1,779.96 | $1,785.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.09 / $2,395.63 / $8,902.00
| Professional | | $2,082.09 | $2,395.63 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.37 / $1,708.76 / $1,993.56
| Professional | | $1,566.37 | $1,708.76 | $1,993.56 |
- 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
- $1,452.45 / $1,779.96 / $2,320.94
| Professional | | $1,452.45 | $1,779.96 | $2,320.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,499.19 / $2,371.23
| Professional | | $29.27 | $1,499.19 | $2,371.23 |