- 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
- $1,615.33 / $1,615.33 / $1,615.33
| Professional | | $1,615.33 | $1,615.33 | $1,615.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.52 / $2,093.52 / $3,017.13
| Professional | | $2,093.52 | $2,093.52 | $3,017.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.82 / $3,123.19 / $3,861.04
| Professional | | $2,853.82 | $3,123.19 | $3,861.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.07 / $2,896.44 / $3,379.18
| Professional | | $2,655.07 | $2,896.44 | $3,379.18 |
- 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
- $2,461.96 / $3,164.04 / $4,115.35
| Professional | | $2,461.96 | $3,164.04 | $4,115.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,248.69 / $3,359.82
| Professional | | $29.27 | $2,248.69 | $3,359.82 |