- 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
- $1,676.71 / $1,676.71 / $1,676.71
| Professional | | $1,676.71 | $1,676.71 | $1,676.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.91 / $2,090.91 / $2,160.98
| Professional | | $2,090.91 | $2,090.91 | $2,160.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.41 / $2,639.03 / $3,262.49
| Professional | | $2,411.41 | $2,639.03 | $3,262.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.00 / $2,007.28 / $2,341.82
| Professional | | $1,840.00 | $2,007.28 | $2,341.82 |
- 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
- $1,706.18 / $2,129.40 / $2,774.49
| Professional | | $1,706.18 | $2,129.40 | $2,774.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,139.81 / $2,994.37
| Professional | | $29.27 | $2,139.81 | $2,994.37 |