- 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
- $1,501.90 / $1,611.87 / $2,064.63
| Professional | | $1,501.90 | $1,611.87 | $2,064.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.58 / $2,093.71 / $4,329.30
| Professional | | $1,640.58 | $2,093.71 | $4,329.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.73 / $2,529.89 / $2,909.37
| Professional | | $2,251.73 | $2,529.89 | $2,909.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.47 / $2,009.96 / $2,344.96
| Professional | | $1,775.47 | $2,009.96 | $2,344.96 |
- 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
- $1,659.97 / $2,093.71 / $2,877.48
| Professional | | $1,659.97 | $2,093.71 | $2,877.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,653.98 / $2,634.41
| Professional | | $29.27 | $1,653.98 | $2,634.41 |