- 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
- $1,896.84 / $2,241.79 / $2,241.79
| Professional | | $1,896.84 | $2,241.79 | $2,241.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.98 / $3,022.23 / $3,022.23
| Professional | | $2,448.98 | $3,022.23 | $3,022.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,230.86 / $3,629.97 / $4,283.35
| Professional | | $3,230.86 | $3,629.97 | $4,283.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.56 / $2,901.34 / $3,384.89
| Professional | | $2,659.56 | $2,901.34 | $3,384.89 |
- 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
- $2,812.34 / $3,022.23 / $3,920.09
| Professional | | $2,812.34 | $3,022.23 | $3,920.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,961.13 / $3,588.85
| Professional | | $29.27 | $2,961.13 | $3,588.85 |