- 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
- $1,937.99 / $1,937.99 / $2,209.98
| Professional | | $1,937.99 | $1,937.99 | $2,209.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.21 / $2,604.85 / $2,604.85
| Professional | | $2,205.21 | $2,604.85 | $2,604.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,764.85 / $3,106.40 / $3,665.55
| Professional | | $2,764.85 | $3,106.40 | $3,665.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.27 / $2,500.66 / $2,917.43
| Professional | | $2,292.27 | $2,500.66 | $2,917.43 |
- 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
- $2,125.56 / $2,604.85 / $3,355.41
| Professional | | $2,125.56 | $2,604.85 | $3,355.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,100.81 / $2,845.21
| Professional | | $29.27 | $2,100.81 | $2,845.21 |