- 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
- $1,736.51 / $1,736.51 / $1,736.51
| Professional | | $1,736.51 | $1,736.51 | $1,736.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.73 / $2,104.73 / $2,247.98
| Professional | | $2,104.73 | $2,104.73 | $2,247.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.92 / $2,673.53 / $3,305.15
| Professional | | $2,442.92 | $2,673.53 | $3,305.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.16 / $2,020.54 / $2,357.29
| Professional | | $1,852.16 | $2,020.54 | $2,357.29 |
- 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
- $1,717.46 / $2,141.00 / $2,791.05
| Professional | | $1,717.46 | $2,141.00 | $2,791.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,150.44 / $3,207.94
| Professional | | $29.27 | $2,150.44 | $3,207.94 |