- 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
- $2,084.75 / $2,084.75 / $2,084.75
| Professional | | $2,084.75 | $2,084.75 | $2,084.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.96 / $2,476.96 / $2,715.31
| Professional | | $2,476.96 | $2,476.96 | $2,715.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.08 / $3,177.11 / $3,927.70
| Professional | | $2,903.08 | $3,177.11 | $3,927.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.73 / $2,377.88 / $2,774.20
| Professional | | $2,179.73 | $2,377.88 | $2,774.20 |
- 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
- $2,021.20 / $2,556.17 / $3,317.33
| Professional | | $2,021.20 | $2,556.17 | $3,317.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,148.11 / $3,119.45
| Professional | | $29.27 | $2,148.11 | $3,119.45 |