- 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
- $1,894.64 / $1,894.64 / $1,894.64
| Professional | | $1,894.64 | $1,894.64 | $1,894.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.34 / $2,238.34 / $2,456.88
| Professional | | $2,238.34 | $2,238.34 | $2,456.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,625.37 / $2,873.18 / $3,551.97
| Professional | | $2,625.37 | $2,873.18 | $3,551.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.74 / $2,148.80 / $2,506.94
| Professional | | $1,969.74 | $2,148.80 | $2,506.94 |
- 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
- $1,826.48 / $2,309.37 / $3,001.17
| Professional | | $1,826.48 | $2,309.37 | $3,001.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.36 / $2,296.30 / $2,471.44
| Professional | | $311.36 | $2,296.30 | $2,471.44 |