- 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
- $1,878.74 / $1,878.74 / $2,152.73
| Professional | | $1,878.74 | $1,878.74 | $2,152.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.98 / $2,534.89 / $2,534.89
| Professional | | $2,147.98 | $2,534.89 | $2,534.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.83 / $3,028.84 / $3,574.03
| Professional | | $2,695.83 | $3,028.84 | $3,574.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.69 / $2,433.48 / $2,839.07
| Professional | | $2,230.69 | $2,433.48 | $2,839.07 |
- 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
- $2,068.46 / $2,534.89 / $3,270.77
| Professional | | $2,068.46 | $2,534.89 | $3,270.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,035.33 / $2,774.18
| Professional | | $29.27 | $2,035.33 | $2,774.18 |