- 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
- $1,337.40 / $1,628.80 / $1,628.80
| Professional | | $1,337.40 | $1,628.80 | $1,628.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.77 / $2,206.36 / $2,206.36
| Professional | | $1,785.77 | $2,206.36 | $2,206.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.21 / $2,817.90 / $3,175.50
| Professional | | $2,395.21 | $2,817.90 | $3,175.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.60 / $2,118.11 / $2,471.13
| Professional | | $1,941.60 | $2,118.11 | $2,471.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.39 / $2,206.36 / $2,859.53
| Professional | | $1,800.39 | $2,206.36 | $2,859.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,587.32 / $2,222.23
| Professional | | $29.27 | $1,587.32 | $2,222.23 |