- 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
- $1,943.13 / $1,943.13 / $2,208.89
| Professional | | $1,943.13 | $1,943.13 | $2,208.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.25 / $2,608.71 / $2,608.71
| Professional | | $2,205.25 | $2,608.71 | $2,608.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.15 / $3,123.58 / $3,685.82
| Professional | | $2,780.15 | $3,123.58 | $3,685.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.67 / $2,504.36 / $2,921.76
| Professional | | $2,295.67 | $2,504.36 | $2,921.76 |
- 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
- $2,483.75 / $2,608.71 / $3,362.55
| Professional | | $2,483.75 | $2,608.71 | $3,362.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,084.31 / $2,855.83
| Professional | | $29.27 | $2,084.31 | $2,855.83 |