- 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
- $2,336.31 / $2,336.31 / $2,336.31
| Professional | | $2,336.31 | $2,336.31 | $2,336.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,970.06 / $2,531.48 / $3,037.79
| Professional | | $1,970.06 | $2,531.48 | $3,037.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,802.14 / $4,271.81 / $4,912.58
| Professional | | $3,802.14 | $4,271.81 | $4,912.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,227.71 / $2,430.23 / $2,835.27
| Professional | | $2,227.71 | $2,430.23 | $2,835.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.69 / $2,531.48 / $3,279.48
| Professional | | $2,065.69 | $2,531.48 | $3,279.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,448.44 / $3,053.34
| Professional | | $29.27 | $2,448.44 | $3,053.34 |