- 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
- $2,102.85 / $2,102.85 / $3,206.97
| Professional | | $2,102.85 | $2,102.85 | $3,206.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.03 / $2,606.98 / $3,128.37
| Professional | | $2,038.03 | $2,606.98 | $3,128.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.12 / $3,030.50 / $3,577.87
| Professional | | $2,769.12 | $3,030.50 | $3,577.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.14 / $2,502.69 / $2,919.81
| Professional | | $2,294.14 | $2,502.69 | $2,919.81 |
- 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
- $2,127.29 / $2,606.98 / $3,352.80
| Professional | | $2,127.29 | $2,606.98 | $3,352.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,991.21 / $2,849.60
| Professional | | $29.27 | $1,991.21 | $2,849.60 |