- 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
- $1,525.31 / $1,525.31 / $1,525.31
| Professional | | $1,525.31 | $1,525.31 | $1,525.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.89 / $1,959.89 / $2,750.68
| Professional | | $1,959.89 | $1,959.89 | $2,750.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.08 / $2,856.45 / $3,531.28
| Professional | | $2,610.08 | $2,856.45 | $3,531.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.59 / $2,640.65 / $3,080.76
| Professional | | $2,420.59 | $2,640.65 | $3,080.76 |
- 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
- $2,244.55 / $2,750.68 / $3,630.20
| Professional | | $2,244.55 | $2,750.68 | $3,630.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,612.82 / $3,053.61
| Professional | | $29.27 | $2,612.82 | $3,053.61 |