- 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
- $1,840.92 / $1,840.92 / $2,116.79
| Professional | | $1,840.92 | $1,840.92 | $2,116.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.14 / $2,516.44 / $2,516.44
| Professional | | $2,109.14 | $2,516.44 | $2,516.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.76 / $2,998.43 / $3,538.15
| Professional | | $2,668.76 | $2,998.43 | $3,538.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.46 / $2,415.78 / $2,818.41
| Professional | | $2,214.46 | $2,415.78 | $2,818.41 |
- 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
- $2,053.41 / $2,516.44 / $3,224.43
| Professional | | $2,053.41 | $2,516.44 | $3,224.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.29 / $2,398.53 / $3,037.88
| Professional | | $343.29 | $2,398.53 | $3,037.88 |