- 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
- $1,894.28 / $1,894.28 / $1,894.28
| Professional | | $1,894.28 | $1,894.28 | $1,894.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.26 / $2,275.26 / $2,469.42
| Professional | | $2,275.26 | $2,275.26 | $2,469.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.42 / $3,097.59 / $3,829.40
| Professional | | $2,830.42 | $3,097.59 | $3,829.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.23 / $2,184.25 / $2,548.29
| Professional | | $2,002.23 | $2,184.25 | $2,548.29 |
- 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
- $1,856.61 / $2,345.50 / $3,045.68
| Professional | | $1,856.61 | $2,345.50 | $3,045.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,683.92 / $2,515.96
| Professional | | $29.27 | $1,683.92 | $2,515.96 |