- 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
- $1,829.22 / $1,829.22 / $1,829.22
| Professional | | $1,829.22 | $1,829.22 | $1,829.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.69 / $2,294.69 / $2,423.61
| Professional | | $2,294.69 | $2,294.69 | $2,423.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,029.47 / $3,315.42 / $4,098.68
| Professional | | $3,029.47 | $3,315.42 | $4,098.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.78 / $2,326.67 / $2,714.45
| Professional | | $2,132.78 | $2,326.67 | $2,714.45 |
- 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
- $1,977.67 / $2,500.73 / $3,246.36
| Professional | | $1,977.67 | $2,500.73 | $3,246.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,794.11 / $2,680.61
| Professional | | $29.27 | $1,794.11 | $2,680.61 |