- 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
- $1,915.67 / $1,915.67 / $2,194.19
| Professional | | $1,915.67 | $1,915.67 | $2,194.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.46 / $2,592.73 / $2,592.73
| Professional | | $2,190.46 | $2,592.73 | $2,592.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.17 / $3,162.92 / $3,732.25
| Professional | | $2,815.17 | $3,162.92 | $3,732.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.60 / $2,489.02 / $2,903.85
| Professional | | $2,281.60 | $2,489.02 | $2,903.85 |
- 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
- $2,115.66 / $2,592.73 / $3,340.41
| Professional | | $2,115.66 | $2,592.73 | $3,340.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,105.37 / $2,836.98
| Professional | | $29.27 | $2,105.37 | $2,836.98 |