- 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
- $1,513.13 / $1,780.55 / $1,780.55
| Professional | | $1,513.13 | $1,780.55 | $1,780.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.53 / $2,422.58 / $2,422.58
| Professional | | $1,949.53 | $2,422.58 | $2,422.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.39 / $2,905.88 / $3,428.94
| Professional | | $2,586.39 | $2,905.88 | $3,428.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.87 / $2,325.67 / $2,713.28
| Professional | | $2,131.87 | $2,325.67 | $2,713.28 |
- 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
- $1,976.82 / $2,422.58 / $3,124.37
| Professional | | $1,976.82 | $2,422.58 | $3,124.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,370.44 / $2,790.97
| Professional | | $29.27 | $2,370.44 | $2,790.97 |