- 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
- $1,564.58 / $1,564.58 / $1,626.72
| Professional | | $1,564.58 | $1,564.58 | $1,626.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.88 / $2,153.16 / $2,153.16
| Professional | | $1,549.88 | $2,153.16 | $2,153.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.39 / $2,566.58 / $3,028.56
| Professional | | $2,284.39 | $2,566.58 | $3,028.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.78 / $2,067.04 / $2,411.54
| Professional | | $1,894.78 | $2,067.04 | $2,411.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.98 / $2,153.16 / $2,763.95
| Professional | | $1,756.98 | $2,153.16 | $2,763.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,620.79 / $2,350.78
| Professional | | $29.27 | $1,620.79 | $2,350.78 |