- 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
- $1,905.91 / $1,905.91 / $2,566.80
| Professional | | $1,905.91 | $1,905.91 | $2,566.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,444.06 / $3,020.03 / $3,020.03
| Professional | | $2,444.06 | $3,020.03 | $3,020.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,217.62 / $3,615.10 / $4,265.82
| Professional | | $3,217.62 | $3,615.10 | $4,265.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.62 / $2,899.22 / $3,382.43
| Professional | | $2,657.62 | $2,899.22 | $3,382.43 |
- 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
- $2,464.34 / $3,020.03 / $3,907.38
| Professional | | $2,464.34 | $3,020.03 | $3,907.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,198.81 / $3,311.14
| Professional | | $29.27 | $2,198.81 | $3,311.14 |