- 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
- $2,327.27 / $2,327.27 / $2,327.27
| Professional | | $2,327.27 | $2,327.27 | $2,327.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.06 / $2,537.53 / $3,045.03
| Professional | | $1,974.06 | $2,537.53 | $3,045.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,736.17 / $4,197.68 / $4,827.34
| Professional | | $3,736.17 | $4,197.68 | $4,827.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.02 / $2,436.02 / $2,842.03
| Professional | | $2,233.02 | $2,436.02 | $2,842.03 |
- 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
- $2,070.62 / $2,537.53 / $3,285.68
| Professional | | $2,070.62 | $2,537.53 | $3,285.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,453.41 / $3,025.32
| Professional | | $29.27 | $2,453.41 | $3,025.32 |