- 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
- $1,634.77 / $1,746.29 / $1,746.29
| Professional | | $1,634.77 | $1,746.29 | $1,746.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.17 / $2,096.17 / $2,271.34
| Professional | | $2,096.17 | $2,096.17 | $2,271.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.05 / $2,664.90 / $3,294.47
| Professional | | $2,435.05 | $2,664.90 | $3,294.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.63 / $2,012.33 / $2,347.71
| Professional | | $1,844.63 | $2,012.33 | $2,347.71 |
- 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
- $1,710.48 / $2,154.83 / $2,801.16
| Professional | | $1,710.48 | $2,154.83 | $2,801.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,153.52 / $3,189.01
| Professional | | $29.27 | $2,153.52 | $3,189.01 |