- 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
- $2,243.44 / $2,243.44 / $2,243.44
| Professional | | $2,243.44 | $2,243.44 | $2,243.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.55 / $2,690.55 / $2,922.47
| Professional | | $2,690.55 | $2,690.55 | $2,922.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,143.67 / $3,440.40 / $4,253.18
| Professional | | $3,143.67 | $3,440.40 | $4,253.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.67 / $2,582.92 / $3,013.42
| Professional | | $2,367.67 | $2,582.92 | $3,013.42 |
- 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
- $2,195.48 / $2,780.57 / $3,610.08
| Professional | | $2,195.48 | $2,780.57 | $3,610.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,273.46 / $3,390.37
| Professional | | $29.27 | $2,273.46 | $3,390.37 |