- 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
- $1,961.58 / $2,097.21 / $2,431.07
| Professional | | $1,961.58 | $2,097.21 | $2,431.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.58 / $2,361.58 / $2,696.98
| Professional | | $2,361.58 | $2,361.58 | $2,696.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.30 / $3,042.73 / $3,761.58
| Professional | | $2,780.30 | $3,042.73 | $3,761.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.19 / $2,267.11 / $2,644.96
| Professional | | $2,078.19 | $2,267.11 | $2,644.96 |
- 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
- $1,927.05 / $2,443.04 / $3,168.56
| Professional | | $1,927.05 | $2,443.04 | $3,168.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,364.73 / $3,477.78
| Professional | | $29.27 | $2,364.73 | $3,477.78 |