- 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
- $2,178.69 / $2,178.69 / $2,178.69
| Professional | | $2,178.69 | $2,178.69 | $2,178.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.04 / $2,460.04 / $2,865.03
| Professional | | $2,460.04 | $2,460.04 | $2,865.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,013.24 / $3,297.66 / $4,076.74
| Professional | | $3,013.24 | $3,297.66 | $4,076.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.83 / $2,361.64 / $2,755.24
| Professional | | $2,164.83 | $2,361.64 | $2,755.24 |
- 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
- $2,007.39 / $2,592.02 / $3,331.13
| Professional | | $2,007.39 | $2,592.02 | $3,331.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,544.21 / $2,759.82
| Professional | | $29.27 | $2,544.21 | $2,759.82 |