- 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
- $1,990.17 / $2,169.76 / $2,819.26
| Professional | | $1,990.17 | $2,169.76 | $2,819.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.42 / $2,625.73 / $5,500.51
| Professional | | $2,303.42 | $2,625.73 | $5,500.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.90 / $3,462.60 / $3,981.99
| Professional | | $3,081.90 | $3,462.60 | $3,981.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.61 / $2,520.69 / $2,940.81
| Professional | | $2,226.61 | $2,520.69 | $2,940.81 |
- 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
- $2,118.06 / $2,706.41 / $3,912.70
| Professional | | $2,118.06 | $2,706.41 | $3,912.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,181.17 / $3,541.34
| Professional | | $29.27 | $2,181.17 | $3,541.34 |