- 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
- $1,797.76 / $2,137.04 / $2,137.04
| Professional | | $1,797.76 | $2,137.04 | $2,137.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,383.67 / $2,775.91 / $2,940.92
| Professional | | $2,383.67 | $2,775.91 | $2,940.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.37 / $3,558.64 / $4,199.20
| Professional | | $3,167.37 | $3,558.64 | $4,199.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.80 / $2,664.88 / $3,109.02
| Professional | | $2,442.80 | $2,664.88 | $3,109.02 |
- 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
- $2,265.14 / $2,775.91 / $3,697.70
| Professional | | $2,265.14 | $2,775.91 | $3,697.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,765.84 / $3,063.88
| Professional | | $29.27 | $2,765.84 | $3,063.88 |