- 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
- $1,598.14 / $1,890.91 / $1,890.91
| Professional | | $1,598.14 | $1,890.91 | $1,890.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.21 / $2,509.69 / $2,509.69
| Professional | | $2,068.21 | $2,509.69 | $2,509.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,674.55 / $3,004.94 / $3,545.83
| Professional | | $2,674.55 | $3,004.94 | $3,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.53 / $2,409.30 / $2,810.85
| Professional | | $2,208.53 | $2,409.30 | $2,810.85 |
- 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
- $2,047.91 / $2,509.69 / $3,241.19
| Professional | | $2,047.91 | $2,509.69 | $3,241.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,451.25 / $2,817.08
| Professional | | $29.27 | $2,451.25 | $2,817.08 |