- 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
- $1,437.27 / $1,437.27 / $1,437.27
| Professional | | $1,437.27 | $1,437.27 | $1,437.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.47 / $1,843.47 / $2,554.53
| Professional | | $1,843.47 | $1,843.47 | $2,554.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.02 / $2,683.48 / $3,317.44
| Professional | | $2,452.02 | $2,683.48 | $3,317.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.98 / $2,452.34 / $2,861.07
| Professional | | $2,247.98 | $2,452.34 | $2,861.07 |
- 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
- $2,084.48 / $2,554.53 / $3,367.59
| Professional | | $2,084.48 | $2,554.53 | $3,367.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,465.37 / $2,834.39
| Professional | | $29.27 | $2,465.37 | $2,834.39 |