- 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
- $1,723.74 / $1,723.74 / $1,723.74
| Professional | | $1,723.74 | $1,723.74 | $1,723.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.08 / $2,075.04 / $2,490.05
| Professional | | $1,620.08 | $2,075.04 | $2,490.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.94 / $2,427.30 / $2,865.72
| Professional | | $2,217.94 | $2,427.30 | $2,865.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.03 / $1,992.04 / $2,324.04
| Professional | | $1,826.03 | $1,992.04 | $2,324.04 |
- 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
- $1,693.23 / $2,075.04 / $2,659.08
| Professional | | $1,693.23 | $2,075.04 | $2,659.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,594.93 / $2,263.73
| Professional | | $29.27 | $1,594.93 | $2,263.73 |