- 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
- $1,696.81 / $1,771.37 / $1,771.37
| Professional | | $1,696.81 | $1,771.37 | $1,771.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.04 / $2,010.83 / $2,024.56
| Professional | | $1,635.04 | $2,010.83 | $2,024.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.39 / $2,616.01 / $3,086.89
| Professional | | $2,328.39 | $2,616.01 | $3,086.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.53 / $1,930.39 / $2,252.12
| Professional | | $1,769.53 | $1,930.39 | $2,252.12 |
- 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
- $2,010.83 / $2,010.83 / $2,634.35
| Professional | | $2,010.83 | $2,010.83 | $2,634.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,686.39 / $2,648.92
| Professional | | $29.27 | $1,686.39 | $2,648.92 |