- 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
- $1,559.69 / $1,559.69 / $1,559.69
| Professional | | $1,559.69 | $1,559.69 | $1,559.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.68 / $1,877.68 / $2,024.57
| Professional | | $1,877.68 | $1,877.68 | $2,024.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.26 / $2,397.00 / $2,963.30
| Professional | | $2,190.26 | $2,397.00 | $2,963.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.35 / $1,802.57 / $2,103.00
| Professional | | $1,652.35 | $1,802.57 | $2,103.00 |
- 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
- $1,532.18 / $1,920.23 / $2,497.04
| Professional | | $1,532.18 | $1,920.23 | $2,497.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,757.76 / $2,555.64
| Professional | | $29.27 | $1,757.76 | $2,555.64 |