- 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
- $1,454.48 / $1,454.48 / $1,725.38
| Professional | | $1,454.48 | $1,454.48 | $1,725.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.82 / $2,052.48 / $2,052.48
| Professional | | $1,719.82 | $2,052.48 | $2,052.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,177.48 / $2,446.46 / $2,886.83
| Professional | | $2,177.48 | $2,446.46 | $2,886.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.18 / $1,970.38 / $2,298.77
| Professional | | $1,806.18 | $1,970.38 | $2,298.77 |
- 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
- $1,674.82 / $2,052.48 / $2,630.15
| Professional | | $1,674.82 | $2,052.48 | $2,630.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,512.79 / $2,240.78
| Professional | | $29.27 | $1,512.79 | $2,240.78 |