- 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
- $1,422.94 / $1,422.94 / $1,511.82
| Professional | | $1,422.94 | $1,422.94 | $1,511.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.65 / $1,886.49 / $1,886.49
| Professional | | $1,490.65 | $1,886.49 | $1,886.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.54 / $2,235.31 / $2,637.67
| Professional | | $1,989.54 | $2,235.31 | $2,637.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.11 / $1,811.03 / $2,112.87
| Professional | | $1,660.11 | $1,811.03 | $2,112.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.37 / $1,886.49 / $2,362.89
| Professional | | $1,539.37 | $1,886.49 | $2,362.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,359.58 / $2,281.32
| Professional | | $29.27 | $1,359.58 | $2,281.32 |