- 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
- $1,416.26 / $1,416.26 / $1,642.54
| Professional | | $1,416.26 | $1,416.26 | $1,642.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.50 / $1,941.50 / $1,941.50
| Professional | | $1,638.50 | $1,941.50 | $1,941.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.64 / $2,317.44 / $2,734.58
| Professional | | $2,062.64 | $2,317.44 | $2,734.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.52 / $1,863.84 / $2,174.48
| Professional | | $1,708.52 | $1,863.84 | $2,174.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.26 / $1,941.50 / $2,496.39
| Professional | | $1,584.26 | $1,941.50 | $2,496.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,539.72 / $2,122.60
| Professional | | $29.27 | $1,539.72 | $2,122.60 |