- 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
- $1,623.51 / $1,734.31 / $1,734.31
| Professional | | $1,623.51 | $1,734.31 | $1,734.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.40 / $2,102.40 / $2,237.38
| Professional | | $2,102.40 | $2,102.40 | $2,237.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.63 / $2,672.10 / $3,303.39
| Professional | | $2,441.63 | $2,672.10 | $3,303.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.11 / $2,018.30 / $2,354.69
| Professional | | $1,850.11 | $2,018.30 | $2,354.69 |
- 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
- $1,715.56 / $2,142.17 / $2,791.34
| Professional | | $1,715.56 | $2,142.17 | $2,791.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,149.33 / $3,172.42
| Professional | | $29.27 | $2,149.33 | $3,172.42 |