- 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
- $1,615.31 / $1,615.31 / $1,615.31
| Professional | | $1,615.31 | $1,615.31 | $1,615.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.36 / $1,699.36 / $2,088.71
| Professional | | $1,699.36 | $1,699.36 | $2,088.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.63 / $2,262.79 / $2,797.38
| Professional | | $2,067.63 | $2,262.79 | $2,797.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.44 / $1,631.39 / $1,903.29
| Professional | | $1,495.44 | $1,631.39 | $1,903.29 |
- 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
- $1,386.68 / $1,780.91 / $2,292.27
| Professional | | $1,386.68 | $1,780.91 | $2,292.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,867.88 / $2,767.95
| Professional | | $29.27 | $1,867.88 | $2,767.95 |