- 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
- $2,142.12 / $2,142.12 / $2,142.12
| Professional | | $2,142.12 | $2,142.12 | $2,142.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.11 / $2,664.11 / $2,670.65
| Professional | | $2,664.11 | $2,664.11 | $2,670.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,895.77 / $3,169.11 / $3,917.81
| Professional | | $2,895.77 | $3,169.11 | $3,917.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.42 / $2,557.55 / $2,983.81
| Professional | | $2,344.42 | $2,557.55 | $2,983.81 |
- 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
- $2,173.92 / $2,766.75 / $3,584.58
| Professional | | $2,173.92 | $2,766.75 | $3,584.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,401.60 / $3,491.64
| Professional | | $29.27 | $2,401.60 | $3,491.64 |