- 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
- $1,711.67 / $1,711.67 / $1,711.67
| Professional | | $1,711.67 | $1,711.67 | $1,711.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.94 / $2,118.94 / $2,161.09
| Professional | | $2,118.94 | $2,118.94 | $2,161.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.42 / $2,626.99 / $3,247.62
| Professional | | $2,400.42 | $2,626.99 | $3,247.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.76 / $2,074.64 / $2,420.42
| Professional | | $1,901.76 | $2,074.64 | $2,420.42 |
- 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
- $1,763.45 / $2,205.46 / $2,871.92
| Professional | | $1,763.45 | $2,205.46 | $2,871.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,211.96 / $3,316.63
| Professional | | $29.27 | $2,211.96 | $3,316.63 |