- 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
- $2,623.22 / $2,623.22 / $2,623.22
| Professional | | $2,623.22 | $2,623.22 | $2,623.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,195.21 / $3,195.21 / $3,391.16
| Professional | | $3,195.21 | $3,195.21 | $3,391.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,693.13 / $4,041.73 / $4,996.59
| Professional | | $3,693.13 | $4,041.73 | $4,996.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,811.79 / $3,067.40 / $3,578.64
| Professional | | $2,811.79 | $3,067.40 | $3,578.64 |
- 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
- $2,607.29 / $3,258.03 / $4,243.18
| Professional | | $2,607.29 | $3,258.03 | $4,243.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,139.07 / $4,598.96
| Professional | | $29.27 | $3,139.07 | $4,598.96 |