- 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
- $2,131.96 / $2,351.51 / $2,938.96
| Professional | | $2,131.96 | $2,351.51 | $2,938.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.23 / $2,939.01 / $6,130.61
| Professional | | $2,398.23 | $2,939.01 | $6,130.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,164.92 / $3,555.89 / $4,089.27
| Professional | | $3,164.92 | $3,555.89 | $4,089.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.28 / $2,821.45 / $3,291.69
| Professional | | $2,492.28 | $2,821.45 | $3,291.69 |
- 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
- $2,341.21 / $2,939.01 / $4,056.71
| Professional | | $2,341.21 | $2,939.01 | $4,056.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,162.79 / $3,447.99
| Professional | | $29.27 | $2,162.79 | $3,447.99 |