- 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
- $1,418.94 / $1,490.25 / $1,490.25
| Professional | | $1,418.94 | $1,490.25 | $1,490.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.06 / $1,697.35 / $1,699.68
| Professional | | $1,372.06 | $1,697.35 | $1,699.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.35 / $2,201.39 / $2,597.64
| Professional | | $1,959.35 | $2,201.39 | $2,597.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.67 / $1,629.46 / $1,901.03
| Professional | | $1,493.67 | $1,629.46 | $1,901.03 |
- 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
- $1,385.04 / $1,697.35 / $2,208.41
| Professional | | $1,385.04 | $1,697.35 | $2,208.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,217.71 / $1,833.73
| Professional | | $29.27 | $1,217.71 | $1,833.73 |