- 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
- $1,528.34 / $1,528.34 / $1,528.34
| Professional | | $1,528.34 | $1,528.34 | $1,528.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.66 / $1,716.66 / $2,001.00
| Professional | | $1,716.66 | $1,716.66 | $2,001.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.14 / $2,276.48 / $2,814.30
| Professional | | $2,080.14 | $2,276.48 | $2,814.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.66 / $1,648.00 / $1,922.66
| Professional | | $1,510.66 | $1,648.00 | $1,922.66 |
- 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
- $1,400.80 / $1,799.53 / $2,316.19
| Professional | | $1,400.80 | $1,799.53 | $2,316.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,888.83 / $2,794.16
| Professional | | $29.27 | $1,888.83 | $2,794.16 |