- 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
- $1,361.08 / $1,361.08 / $1,412.82
| Professional | | $1,361.08 | $1,361.08 | $1,412.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.65 / $1,702.46 / $1,702.46
| Professional | | $1,382.65 | $1,702.46 | $1,702.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.24 / $2,047.34 / $2,415.86
| Professional | | $1,822.24 | $2,047.34 | $2,415.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.17 / $1,634.36 / $1,906.76
| Professional | | $1,498.17 | $1,634.36 | $1,906.76 |
- 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
- $1,389.21 / $1,702.46 / $2,209.23
| Professional | | $1,389.21 | $1,702.46 | $2,209.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,275.45 / $2,008.34
| Professional | | $29.27 | $1,275.45 | $2,008.34 |