- 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
- $1,802.63 / $1,802.63 / $1,802.63
| Professional | | $1,802.63 | $1,802.63 | $1,802.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.39 / $1,804.39 / $2,263.58
| Professional | | $1,804.39 | $1,804.39 | $2,263.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.88 / $2,933.40 / $3,532.36
| Professional | | $2,610.88 | $2,933.40 | $3,532.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.86 / $1,732.21 / $2,020.91
| Professional | | $1,587.86 | $1,732.21 | $2,020.91 |
- 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
- $1,472.38 / $1,878.84 / $2,432.98
| Professional | | $1,472.38 | $1,878.84 | $2,432.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.63 / $1,342.12 / $2,005.28
| Professional | | $252.63 | $1,342.12 | $2,005.28 |