- 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
- $1,425.30 / $1,495.14 / $2,116.13
| Professional | | $1,425.30 | $1,495.14 | $2,116.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.28 / $1,706.85 / $1,706.85
| Professional | | $1,380.28 | $1,706.85 | $1,706.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.67 / $2,235.46 / $2,637.84
| Professional | | $1,989.67 | $2,235.46 | $2,637.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.03 / $1,638.58 / $1,911.67
| Professional | | $1,502.03 | $1,638.58 | $1,911.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.79 / $1,706.85 / $2,223.08
| Professional | | $1,392.79 | $1,706.85 | $2,223.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,451.36 / $2,221.06
| Professional | | $29.27 | $1,451.36 | $2,221.06 |