- 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
- $1,971.01 / $1,971.01 / $1,971.01
| Professional | | $1,971.01 | $1,971.01 | $1,971.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,360.75 / $2,360.75 / $2,582.44
| Professional | | $2,360.75 | $2,360.75 | $2,582.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.18 / $2,932.07 / $3,624.78
| Professional | | $2,679.18 | $2,932.07 | $3,624.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.46 / $2,266.32 / $2,644.04
| Professional | | $2,077.46 | $2,266.32 | $2,644.04 |
- 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
- $1,926.37 / $2,453.91 / $3,178.88
| Professional | | $1,926.37 | $2,453.91 | $3,178.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,843.31 / $2,694.61
| Professional | | $29.27 | $1,843.31 | $2,694.61 |