- 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
- $2,165.01 / $2,165.01 / $2,165.01
| Professional | | $2,165.01 | $2,165.01 | $2,165.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.29 / $2,690.29 / $2,717.24
| Professional | | $2,690.29 | $2,690.29 | $2,717.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,175.03 / $3,474.72 / $4,295.63
| Professional | | $3,175.03 | $3,474.72 | $4,295.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.17 / $2,608.55 / $3,043.31
| Professional | | $2,391.17 | $2,608.55 | $3,043.31 |
- 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
- $2,217.27 / $2,795.68 / $3,631.40
| Professional | | $2,217.27 | $2,795.68 | $3,631.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,738.96 / $3,999.52
| Professional | | $29.27 | $2,738.96 | $3,999.52 |