- 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
- $1,819.32 / $1,938.86 / $1,938.86
| Professional | | $1,819.32 | $1,938.86 | $1,938.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,348.65 / $2,348.65 / $2,517.75
| Professional | | $2,348.65 | $2,348.65 | $2,517.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.89 / $3,005.08 / $3,715.03
| Professional | | $2,745.89 | $3,005.08 | $3,715.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.81 / $2,254.69 / $2,630.49
| Professional | | $2,066.81 | $2,254.69 | $2,630.49 |
- 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
- $1,916.50 / $2,425.80 / $3,143.76
| Professional | | $1,916.50 | $2,425.80 | $3,143.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,886.02 / $2,749.85
| Professional | | $29.27 | $1,886.02 | $2,749.85 |