- 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
- $1,648.32 / $1,648.32 / $1,741.81
| Professional | | $1,648.32 | $1,648.32 | $1,741.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.82 / $2,017.81 / $2,017.81
| Professional | | $1,715.82 | $2,017.81 | $2,017.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.73 / $2,434.38 / $2,872.57
| Professional | | $2,166.73 | $2,434.38 | $2,872.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.68 / $1,937.10 / $2,259.94
| Professional | | $1,775.68 | $1,937.10 | $2,259.94 |
- 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
- $1,646.54 / $2,125.17 / $2,768.18
| Professional | | $1,646.54 | $2,125.17 | $2,768.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,478.24 / $2,226.05
| Professional | | $29.27 | $1,478.24 | $2,226.05 |