- 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
- $1,854.50 / $1,854.50 / $2,126.44
| Professional | | $1,854.50 | $1,854.50 | $2,126.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.30 / $2,514.17 / $2,514.17
| Professional | | $2,122.30 | $2,514.17 | $2,514.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.62 / $3,003.89 / $3,544.59
| Professional | | $2,673.62 | $3,003.89 | $3,544.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,212.46 / $2,413.61 / $2,815.88
| Professional | | $2,212.46 | $2,413.61 | $2,815.88 |
- 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
- $2,367.42 / $2,390.92 / $3,237.86
| Professional | | $2,367.42 | $2,390.92 | $3,237.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,036.35 / $2,751.33
| Professional | | $29.27 | $2,036.35 | $2,751.33 |