- 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
- $1,787.99 / $1,787.99 / $1,787.99
| Professional | | $1,787.99 | $1,787.99 | $1,787.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.38 / $2,139.38 / $2,247.92
| Professional | | $2,139.38 | $2,139.38 | $2,247.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.17 / $3,085.41 / $3,715.41
| Professional | | $2,746.17 | $3,085.41 | $3,715.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,882.65 / $2,053.80 / $2,396.10
| Professional | | $1,882.65 | $2,053.80 | $2,396.10 |
- 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
- $1,745.73 / $2,249.96 / $2,892.98
| Professional | | $1,745.73 | $2,249.96 | $2,892.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,211.13 / $2,398.62
| Professional | | $29.27 | $2,211.13 | $2,398.62 |