- 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
- $1,604.46 / $1,744.24 / $3,193.89
| Professional | | $1,604.46 | $1,744.24 | $3,193.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.73 / $2,546.21 / $2,546.21
| Professional | | $1,674.73 | $2,546.21 | $2,546.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.67 / $3,070.24 / $3,622.88
| Professional | | $2,732.67 | $3,070.24 | $3,622.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.67 / $2,444.36 / $2,851.76
| Professional | | $2,240.67 | $2,444.36 | $2,851.76 |
- 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
- $2,077.71 / $2,546.21 / $3,325.34
| Professional | | $2,077.71 | $2,546.21 | $3,325.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,867.41 / $2,812.10
| Professional | | $29.27 | $1,867.41 | $2,812.10 |