- 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
- $1,873.00 / $2,002.12 / $2,270.52
| Professional | | $1,873.00 | $2,002.12 | $2,270.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.02 / $2,666.69 / $2,684.27
| Professional | | $2,267.02 | $2,666.69 | $2,684.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,863.52 / $3,217.25 / $3,796.36
| Professional | | $2,863.52 | $3,217.25 | $3,796.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,346.69 / $2,560.02 / $2,986.69
| Professional | | $2,346.69 | $2,560.02 | $2,986.69 |
- 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
- $2,176.02 / $2,666.69 / $3,448.73
| Professional | | $2,176.02 | $2,666.69 | $3,448.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,188.87 / $2,921.89
| Professional | | $29.27 | $2,188.87 | $2,921.89 |