- 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
- $1,640.12 / $1,640.12 / $1,640.12
| Professional | | $1,640.12 | $1,640.12 | $1,640.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.19 / $2,009.19 / $2,117.66
| Professional | | $2,009.19 | $2,009.19 | $2,117.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.17 / $2,552.31 / $3,155.30
| Professional | | $2,332.17 | $2,552.31 | $3,155.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.09 / $1,928.82 / $2,250.29
| Professional | | $1,768.09 | $1,928.82 | $2,250.29 |
- 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
- $1,639.50 / $2,044.37 / $2,664.72
| Professional | | $1,639.50 | $2,044.37 | $2,664.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,971.63 / $2,947.09
| Professional | | $29.27 | $1,971.63 | $2,947.09 |