- 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
- $1,677.69 / $1,677.69 / $2,170.69
| Professional | | $1,677.69 | $1,677.69 | $2,170.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.58 / $2,550.80 / $2,550.80
| Professional | | $2,168.58 | $2,550.80 | $2,550.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,714.87 / $3,050.23 / $3,599.27
| Professional | | $2,714.87 | $3,050.23 | $3,599.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.69 / $2,448.77 / $2,856.90
| Professional | | $2,244.69 | $2,448.77 | $2,856.90 |
- 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
- $2,081.44 / $2,550.80 / $3,297.75
| Professional | | $2,081.44 | $2,550.80 | $3,297.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,857.08 / $2,793.77
| Professional | | $29.27 | $1,857.08 | $2,793.77 |