- 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
- $1,649.80 / $1,649.81 / $1,890.46
| Professional | | $1,649.80 | $1,649.81 | $1,890.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.87 / $2,243.41 / $2,243.41
| Professional | | $1,884.87 | $2,243.41 | $2,243.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.05 / $2,676.30 / $3,158.03
| Professional | | $2,382.05 | $2,676.30 | $3,158.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.20 / $2,153.67 / $2,512.62
| Professional | | $1,974.20 | $2,153.67 | $2,512.62 |
- 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
- $1,830.62 / $2,243.41 / $2,878.70
| Professional | | $1,830.62 | $2,243.41 | $2,878.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,756.22 / $2,451.28
| Professional | | $29.27 | $1,756.22 | $2,451.28 |