- 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
- $1,423.07 / $1,423.07 / $1,621.70
| Professional | | $1,423.07 | $1,423.07 | $1,621.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.03 / $1,922.31 / $1,922.31
| Professional | | $1,616.03 | $1,922.31 | $1,922.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.42 / $2,289.11 / $2,701.15
| Professional | | $2,037.42 | $2,289.11 | $2,701.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.64 / $1,845.42 / $2,152.98
| Professional | | $1,691.64 | $1,845.42 | $2,152.98 |
- 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
- $1,568.61 / $1,922.31 / $2,464.53
| Professional | | $1,568.61 | $1,922.31 | $2,464.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,535.11 / $2,096.64
| Professional | | $29.27 | $1,535.11 | $2,096.64 |