- 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
- $1,996.33 / $1,996.33 / $1,996.33
| Professional | | $1,996.33 | $1,996.33 | $1,996.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.00 / $2,492.00 / $2,492.89
| Professional | | $2,492.00 | $2,492.00 | $2,492.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.22 / $3,098.46 / $3,830.48
| Professional | | $2,831.22 | $3,098.46 | $3,830.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.73 / $2,393.17 / $2,792.03
| Professional | | $2,193.73 | $2,393.17 | $2,792.03 |
- 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
- $2,034.20 / $2,591.89 / $3,356.78
| Professional | | $2,034.20 | $2,591.89 | $3,356.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,285.48 / $3,323.30
| Professional | | $29.27 | $2,285.48 | $3,323.30 |