- 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
- $1,880.15 / $1,880.15 / $1,880.15
| Professional | | $1,880.15 | $1,880.15 | $1,880.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.96 / $2,183.96 / $2,471.27
| Professional | | $2,183.96 | $2,183.96 | $2,471.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,596.73 / $2,841.84 / $3,513.23
| Professional | | $2,596.73 | $2,841.84 | $3,513.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,096.60 / $2,446.04
| Professional | | $1,921.89 | $2,096.60 | $2,446.04 |
- 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
- $1,782.11 / $2,283.16 / $2,941.32
| Professional | | $1,782.11 | $2,283.16 | $2,941.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,191.77 / $3,281.76
| Professional | | $29.27 | $2,191.77 | $3,281.76 |