- 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
- $1,885.48 / $1,885.48 / $1,885.48
| Professional | | $1,885.48 | $1,885.48 | $1,885.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.27 / $2,288.76 / $2,746.52
| Professional | | $1,787.27 | $2,288.76 | $2,746.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.33 / $2,655.35 / $3,134.96
| Professional | | $2,426.33 | $2,655.35 | $3,134.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.11 / $2,197.21 / $2,563.41
| Professional | | $2,014.11 | $2,197.21 | $2,563.41 |
- 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
- $1,867.63 / $2,288.76 / $2,930.75
| Professional | | $1,867.63 | $2,288.76 | $2,930.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,824.69 / $2,496.84
| Professional | | $29.27 | $1,824.69 | $2,496.84 |