- 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
- $1,840.23 / $2,066.29 / $2,537.73
| Professional | | $1,840.23 | $2,066.29 | $2,537.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.99 / $2,574.33 / $5,344.56
| Professional | | $1,883.99 | $2,574.33 | $5,344.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.32 / $3,127.14 / $3,596.21
| Professional | | $2,783.32 | $3,127.14 | $3,596.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.03 / $2,471.35 / $2,883.24
| Professional | | $2,183.03 | $2,471.35 | $2,883.24 |
- 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
- $2,044.66 / $2,612.62 / $3,814.79
| Professional | | $2,044.66 | $2,612.62 | $3,814.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,902.02 / $2,864.22
| Professional | | $29.27 | $1,902.02 | $2,864.22 |