- 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
- $1,611.23 / $1,611.23 / $1,981.14
| Professional | | $1,611.23 | $1,611.23 | $1,981.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.16 / $2,342.01 / $2,342.01
| Professional | | $1,978.16 | $2,342.01 | $2,342.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.98 / $2,802.07 / $3,306.44
| Professional | | $2,493.98 | $2,802.07 | $3,306.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.96 / $2,248.33 / $2,623.05
| Professional | | $2,060.96 | $2,248.33 | $2,623.05 |
- 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
- $1,911.08 / $2,342.01 / $3,019.76
| Professional | | $1,911.08 | $2,342.01 | $3,019.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,871.60 / $2,566.48
| Professional | | $29.27 | $1,871.60 | $2,566.48 |