- 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
- $1,898.52 / $1,898.52 / $1,898.52
| Professional | | $1,898.52 | $1,898.52 | $1,898.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.39 / $2,311.39 / $2,458.67
| Professional | | $2,311.39 | $2,311.39 | $2,458.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.48 / $2,963.04 / $3,663.06
| Professional | | $2,707.48 | $2,963.04 | $3,663.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.02 / $2,218.92 / $2,588.75
| Professional | | $2,034.02 | $2,218.92 | $2,588.75 |
- 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
- $1,886.09 / $2,382.80 / $3,093.60
| Professional | | $1,886.09 | $2,382.80 | $3,093.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,374.57 / $3,518.91
| Professional | | $29.27 | $2,374.57 | $3,518.91 |