- 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
- $2,044.76 / $2,044.76 / $2,329.35
| Professional | | $2,044.76 | $2,044.76 | $2,329.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.46 / $2,747.13 / $2,747.13
| Professional | | $2,326.46 | $2,747.13 | $2,747.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.99 / $3,304.29 / $3,899.06
| Professional | | $2,940.99 | $3,304.29 | $3,899.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.46 / $2,637.24 / $3,076.78
| Professional | | $2,417.46 | $2,637.24 | $3,076.78 |
- 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
- $2,241.65 / $2,747.13 / $3,544.65
| Professional | | $2,241.65 | $2,747.13 | $3,544.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,233.94 / $3,008.14
| Professional | | $29.27 | $2,233.94 | $3,008.14 |