- 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
- $2,504.44 / $2,504.44 / $2,504.44
| Professional | | $2,504.44 | $2,504.44 | $2,504.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,738.93 / $2,738.93 / $3,268.53
| Professional | | $2,738.93 | $2,738.93 | $3,268.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,462.28 / $3,789.09 / $4,684.26
| Professional | | $3,462.28 | $3,789.09 | $4,684.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.25 / $2,629.37 / $3,067.60
| Professional | | $2,410.25 | $2,629.37 | $3,067.60 |
- 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
- $2,234.96 / $2,889.54 / $3,711.96
| Professional | | $2,234.96 | $2,889.54 | $3,711.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,833.89 / $3,168.55
| Professional | | $29.27 | $2,833.89 | $3,168.55 |