- 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
- $1,817.60 / $1,817.60 / $1,926.82
| Professional | | $1,817.60 | $1,817.60 | $1,926.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.53 / $2,401.06 / $2,434.23
| Professional | | $1,834.53 | $2,401.06 | $2,434.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.21 / $2,868.61 / $3,384.96
| Professional | | $2,553.21 | $2,868.61 | $3,384.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,112.94 / $2,305.02 / $2,689.19
| Professional | | $2,112.94 | $2,305.02 | $2,689.19 |
- 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
- $1,959.27 / $2,401.06 / $3,104.90
| Professional | | $1,959.27 | $2,401.06 | $3,104.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,870.74 / $2,627.42
| Professional | | $29.27 | $1,870.74 | $2,627.42 |