- 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
- $1,681.75 / $1,801.18 / $1,801.18
| Professional | | $1,681.75 | $1,801.18 | $1,801.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.33 / $2,032.33 / $2,317.84
| Professional | | $2,032.33 | $2,032.33 | $2,317.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.21 / $2,600.50 / $3,214.87
| Professional | | $2,376.21 | $2,600.50 | $3,214.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.45 / $1,951.03 / $2,276.19
| Professional | | $1,788.45 | $1,951.03 | $2,276.19 |
- 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
- $1,658.38 / $2,089.79 / $2,715.80
| Professional | | $1,658.38 | $2,089.79 | $2,715.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,061.10 / $3,048.87
| Professional | | $29.27 | $2,061.10 | $3,048.87 |