- 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
- $1,807.75 / $2,025.03 / $2,517.10
| Professional | | $1,807.75 | $2,025.03 | $2,517.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.61 / $2,524.23 / $5,281.91
| Professional | | $1,990.61 | $2,524.23 | $5,281.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.23 / $3,057.39 / $3,516.00
| Professional | | $2,721.23 | $3,057.39 | $3,516.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.54 / $2,423.26 / $2,827.13
| Professional | | $2,140.54 | $2,423.26 | $2,827.13 |
- 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
- $2,021.29 / $2,524.23 / $3,491.55
| Professional | | $2,021.29 | $2,524.23 | $3,491.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,859.59 / $2,800.32
| Professional | | $29.27 | $1,859.59 | $2,800.32 |