- 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
- $1,698.05 / $1,698.05 / $1,698.05
| Professional | | $1,698.05 | $1,698.05 | $1,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.00 / $2,074.00 / $2,193.01
| Professional | | $2,074.00 | $2,074.00 | $2,193.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.69 / $2,599.94 / $3,214.18
| Professional | | $2,375.69 | $2,599.94 | $3,214.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.12 / $1,991.04 / $2,322.88
| Professional | | $1,825.12 | $1,991.04 | $2,322.88 |
- 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
- $1,692.38 / $2,112.11 / $2,752.34
| Professional | | $1,692.38 | $2,112.11 | $2,752.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,120.44 / $3,098.45
| Professional | | $29.27 | $2,120.44 | $3,098.45 |