- 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
- $1,426.16 / $1,573.72 / $1,573.72
| Professional | | $1,426.16 | $1,573.72 | $1,573.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.13 / $2,047.50 / $2,047.50
| Professional | | $1,678.13 | $2,047.50 | $2,047.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.17 / $2,453.98 / $2,895.70
| Professional | | $2,184.17 | $2,453.98 | $2,895.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.80 / $1,965.60 / $2,293.19
| Professional | | $1,801.80 | $1,965.60 | $2,293.19 |
- 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
- $1,670.76 / $2,047.50 / $2,628.51
| Professional | | $1,670.76 | $2,047.50 | $2,628.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,510.19 / $2,247.65
| Professional | | $29.27 | $1,510.19 | $2,247.65 |