- 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
- $1,516.92 / $1,540.22 / $1,540.22
| Professional | | $1,516.92 | $1,540.22 | $1,540.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.90 / $1,845.39 / $1,853.94
| Professional | | $1,492.90 | $1,845.39 | $1,853.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.73 / $2,431.02 / $2,868.60
| Professional | | $2,163.73 | $2,431.02 | $2,868.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.94 / $1,771.57 / $2,066.83
| Professional | | $1,623.94 | $1,771.57 | $2,066.83 |
- 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
- $1,845.39 / $1,845.39 / $2,406.94
| Professional | | $1,845.39 | $1,845.39 | $2,406.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,334.05 / $1,995.66
| Professional | | $29.27 | $1,334.05 | $1,995.66 |