- 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
- $1,534.54 / $1,806.95 / $1,806.95
| Professional | | $1,534.54 | $1,806.95 | $1,806.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.59 / $2,455.53 / $2,455.53
| Professional | | $1,977.59 | $2,455.53 | $2,455.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.76 / $2,945.62 / $3,475.83
| Professional | | $2,621.76 | $2,945.62 | $3,475.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.86 / $2,357.30 / $2,750.19
| Professional | | $2,160.86 | $2,357.30 | $2,750.19 |
- 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
- $2,003.71 / $2,455.53 / $3,167.04
| Professional | | $2,003.71 | $2,455.53 | $3,167.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,402.87 / $2,772.17
| Professional | | $29.27 | $2,402.87 | $2,772.17 |