- 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
- $1,724.97 / $1,724.97 / $1,724.97
| Professional | | $1,724.97 | $1,724.97 | $1,724.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.84 / $2,074.84 / $2,209.85
| Professional | | $2,074.84 | $2,074.84 | $2,209.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.01 / $2,638.59 / $3,261.95
| Professional | | $2,411.01 | $2,638.59 | $3,261.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.86 / $1,991.84 / $2,323.82
| Professional | | $1,825.86 | $1,991.84 | $2,323.82 |
- 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
- $1,693.07 / $2,115.32 / $2,755.86
| Professional | | $1,693.07 | $2,115.32 | $2,755.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,122.42 / $3,103.98
| Professional | | $29.27 | $2,122.42 | $3,103.98 |