- 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
- $1,880.41 / $1,880.41 / $1,880.41
| Professional | | $1,880.41 | $1,880.41 | $1,880.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.76 / $2,125.76 / $2,451.92
| Professional | | $2,125.76 | $2,125.76 | $2,451.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.98 / $3,005.17 / $3,715.14
| Professional | | $2,745.98 | $3,005.17 | $3,715.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.67 / $2,040.73 / $2,380.85
| Professional | | $1,870.67 | $2,040.73 | $2,380.85 |
- 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
- $1,734.62 / $2,235.10 / $2,873.40
| Professional | | $1,734.62 | $2,235.10 | $2,873.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,319.39 / $3,398.00
| Professional | | $29.27 | $2,319.39 | $3,398.00 |