- 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
- $1,615.76 / $1,905.48 / $3,281.37
| Professional | | $1,615.76 | $1,905.48 | $3,281.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.46 / $2,580.16 / $2,580.16
| Professional | | $2,082.46 | $2,580.16 | $2,580.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,757.53 / $3,098.16 / $3,655.83
| Professional | | $2,757.53 | $3,098.16 | $3,655.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.54 / $2,476.96 / $2,889.78
| Professional | | $2,270.54 | $2,476.96 | $2,889.78 |
- 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
- $2,105.41 / $2,580.16 / $3,335.33
| Professional | | $2,105.41 | $2,580.16 | $3,335.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,527.30 / $2,982.00
| Professional | | $29.27 | $2,527.30 | $2,982.00 |