- 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
- $1,712.94 / $2,019.34 / $2,019.34
| Professional | | $1,712.94 | $2,019.34 | $2,019.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.54 / $2,739.80 / $2,739.80
| Professional | | $2,210.54 | $2,739.80 | $2,739.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,923.48 / $3,284.62 / $3,875.85
| Professional | | $2,923.48 | $3,284.62 | $3,875.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.02 / $2,630.21 / $3,068.58
| Professional | | $2,411.02 | $2,630.21 | $3,068.58 |
- 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
- $2,494.04 / $2,842.19 / $3,536.79
| Professional | | $2,494.04 | $2,842.19 | $3,536.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,679.40 / $3,008.45
| Professional | | $29.27 | $2,679.40 | $3,008.45 |