- 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
- $1,235.01 / $1,484.85 / $1,484.85
| Professional | | $1,235.01 | $1,484.85 | $1,484.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.74 / $1,919.93 / $2,035.79
| Professional | | $1,636.74 | $1,919.93 | $2,035.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,236.27 / $2,512.51 / $2,964.76
| Professional | | $2,236.27 | $2,512.51 | $2,964.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.53 / $1,843.13 / $2,150.32
| Professional | | $1,689.53 | $1,843.13 | $2,150.32 |
- 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
- $1,566.66 / $2,012.44 / $2,551.61
| Professional | | $1,566.66 | $2,012.44 | $2,551.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,710.37 / $2,720.72
| Professional | | $29.27 | $1,710.37 | $2,720.72 |