- 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
- $1,608.18 / $1,608.18 / $1,608.18
| Professional | | $1,608.18 | $1,608.18 | $1,608.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.27 / $2,017.76 / $2,421.32
| Professional | | $1,568.27 | $2,017.76 | $2,421.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.03 / $2,325.62 / $2,745.67
| Professional | | $2,125.03 | $2,325.62 | $2,745.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.63 / $1,937.05 / $2,259.89
| Professional | | $1,775.63 | $1,937.05 | $2,259.89 |
- 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
- $1,637.78 / $2,017.76 / $2,595.41
| Professional | | $1,637.78 | $2,017.76 | $2,595.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,649.17 / $2,186.80
| Professional | | $29.27 | $1,649.17 | $2,186.80 |