- 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
- $1,882.21 / $1,882.21 / $1,882.21
| Professional | | $1,882.21 | $1,882.21 | $1,882.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.28 / $2,252.28 / $2,452.03
| Professional | | $2,252.28 | $2,252.28 | $2,452.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,637.81 / $2,886.79 / $3,568.81
| Professional | | $2,637.81 | $2,886.79 | $3,568.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.00 / $2,162.17 / $2,522.55
| Professional | | $1,982.00 | $2,162.17 | $2,522.55 |
- 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
- $1,837.86 / $2,321.09 / $3,014.13
| Professional | | $1,837.86 | $2,321.09 | $3,014.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,283.44 / $3,339.02
| Professional | | $29.27 | $2,283.44 | $3,339.02 |