- 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
- $2,032.39 / $2,032.39 / $2,032.39
| Professional | | $2,032.39 | $2,032.39 | $2,032.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.79 / $2,525.79 / $2,647.85
| Professional | | $2,525.79 | $2,525.79 | $2,647.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.19 / $3,223.19 / $3,984.67
| Professional | | $2,945.19 | $3,223.19 | $3,984.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.69 / $2,424.76 / $2,828.88
| Professional | | $2,222.69 | $2,424.76 | $2,828.88 |
- 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
- $2,061.04 / $2,525.79 / $3,368.24
| Professional | | $2,061.04 | $2,525.79 | $3,368.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,866.24 / $2,788.39
| Professional | | $29.27 | $1,866.24 | $2,788.39 |