- 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
- $947.00 / $1,218.28 / $1,218.28
| Professional | | $947.00 | $1,218.28 | $1,218.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.51 / $1,635.58 / $1,677.14
| Professional | | $1,224.51 | $1,635.58 | $1,677.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.89 / $2,005.38 / $2,366.35
| Professional | | $1,784.89 | $2,005.38 | $2,366.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.31 / $1,570.15 / $1,831.84
| Professional | | $1,439.31 | $1,570.15 | $1,831.84 |
- 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
- $1,635.58 / $1,763.87 / $2,165.98
| Professional | | $1,635.58 | $1,763.87 | $2,165.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,557.66 / $2,450.71
| Professional | | $29.27 | $1,557.66 | $2,450.71 |