- 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
- $1,798.88 / $1,798.88 / $1,798.88
| Professional | | $1,798.88 | $1,798.88 | $1,798.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.98 / $2,329.98 / $2,820.59
| Professional | | $2,329.98 | $2,329.98 | $2,820.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,058.86 / $3,347.59 / $4,138.46
| Professional | | $3,058.86 | $3,347.59 | $4,138.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,482.12 / $2,707.76 / $3,159.06
| Professional | | $2,482.12 | $2,707.76 | $3,159.06 |
- 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
- $2,301.60 / $2,820.59 / $3,783.02
| Professional | | $2,301.60 | $2,820.59 | $3,783.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,124.33 / $3,123.17
| Professional | | $29.27 | $2,124.33 | $3,123.17 |