- 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
- $1,865.60 / $1,865.60 / $1,865.60
| Professional | | $1,865.60 | $1,865.60 | $1,865.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.16 / $2,319.16 / $2,334.60
| Professional | | $2,319.16 | $2,319.16 | $2,334.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.11 / $3,190.27 / $3,943.97
| Professional | | $2,915.11 | $3,190.27 | $3,943.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.44 / $2,241.21 / $2,614.75
| Professional | | $2,054.44 | $2,241.21 | $2,614.75 |
- 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
- $1,905.03 / $2,407.21 / $3,125.15
| Professional | | $1,905.03 | $2,407.21 | $3,125.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,728.14 / $2,582.05
| Professional | | $29.27 | $1,728.14 | $2,582.05 |