- 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
- $1,656.74 / $1,950.22 / $1,950.22
| Professional | | $1,656.74 | $1,950.22 | $1,950.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.94 / $2,645.84 / $2,645.84
| Professional | | $2,135.94 | $2,645.84 | $2,645.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,827.70 / $3,094.62 / $3,748.87
| Professional | | $2,827.70 | $3,094.62 | $3,748.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.34 / $2,540.00 / $2,963.34
| Professional | | $2,328.34 | $2,540.00 | $2,963.34 |
- 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
- $2,159.00 / $2,645.84 / $3,420.95
| Professional | | $2,159.00 | $2,645.84 | $3,420.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,591.62 / $2,909.89
| Professional | | $29.27 | $2,591.62 | $2,909.89 |