- 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
- $2,031.47 / $2,031.47 / $2,031.47
| Professional | | $2,031.47 | $2,031.47 | $2,031.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.59 / $2,540.59 / $2,620.67
| Professional | | $2,540.59 | $2,540.59 | $2,620.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.29 / $3,217.83 / $3,978.05
| Professional | | $2,940.29 | $3,217.83 | $3,978.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.19 / $2,515.85 / $2,935.16
| Professional | | $2,306.19 | $2,515.85 | $2,935.16 |
- 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
- $2,138.46 / $2,709.71 / $3,515.54
| Professional | | $2,138.46 | $2,709.71 | $3,515.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,680.88 / $3,899.56
| Professional | | $29.27 | $2,680.88 | $3,899.56 |