- 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
- $1,528.16 / $1,635.14 / $1,635.14
| Professional | | $1,528.16 | $1,635.14 | $1,635.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.09 / $2,101.09 / $2,112.26
| Professional | | $2,101.09 | $2,101.09 | $2,112.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.87 / $2,510.39 / $3,103.47
| Professional | | $2,293.87 | $2,510.39 | $3,103.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.96 / $2,017.04 / $2,353.21
| Professional | | $1,848.96 | $2,017.04 | $2,353.21 |
- 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
- $1,714.49 / $2,101.09 / $2,808.41
| Professional | | $1,714.49 | $2,101.09 | $2,808.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,043.23 / $2,930.55
| Professional | | $29.27 | $2,043.23 | $2,930.55 |