- 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
- $2,199.91 / $2,199.91 / $2,199.91
| Professional | | $2,199.91 | $2,199.91 | $2,199.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.29 / $2,718.29 / $2,737.91
| Professional | | $2,718.29 | $2,718.29 | $2,737.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.45 / $3,253.02 / $4,021.55
| Professional | | $2,972.45 | $3,253.02 | $4,021.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,392.09 / $2,609.56 / $3,044.48
| Professional | | $2,392.09 | $2,609.56 | $3,044.48 |
- 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
- $2,218.12 / $2,817.19 / $3,651.08
| Professional | | $2,218.12 | $2,817.19 | $3,651.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,799.53 / $4,136.88
| Professional | | $29.27 | $2,799.53 | $4,136.88 |