- 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
- $1,277.20 / $1,342.14 / $1,342.14
| Professional | | $1,277.20 | $1,342.14 | $1,342.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.86 / $1,548.45 / $1,548.45
| Professional | | $1,235.86 | $1,548.45 | $1,548.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.70 / $1,999.55 / $2,359.46
| Professional | | $1,779.70 | $1,999.55 | $2,359.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.64 / $1,486.51 / $1,734.26
| Professional | | $1,362.64 | $1,486.51 | $1,734.26 |
- 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
- $1,263.54 / $1,548.45 / $1,999.91
| Professional | | $1,263.54 | $1,548.45 | $1,999.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,257.33 / $2,010.92
| Professional | | $29.27 | $1,257.33 | $2,010.92 |