- 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
- $1,504.16 / $1,575.23 / $1,575.23
| Professional | | $1,504.16 | $1,575.23 | $1,575.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.49 / $1,791.34 / $1,794.09
| Professional | | $1,449.49 | $1,791.34 | $1,794.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.71 / $2,347.85 / $2,770.46
| Professional | | $2,089.71 | $2,347.85 | $2,770.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.38 / $1,719.68 / $2,006.30
| Professional | | $1,576.38 | $1,719.68 | $2,006.30 |
- 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
- $1,461.73 / $1,791.34 / $2,334.46
| Professional | | $1,461.73 | $1,791.34 | $2,334.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,533.81 / $2,363.39
| Professional | | $29.27 | $1,533.81 | $2,363.39 |