- 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
- $2,063.05 / $2,063.05 / $2,063.05
| Professional | | $2,063.05 | $2,063.05 | $2,063.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.27 / $2,482.30 / $2,978.76
| Professional | | $1,942.27 | $2,482.30 | $2,978.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,674.69 / $2,927.15 / $3,455.85
| Professional | | $2,674.69 | $2,927.15 | $3,455.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.42 / $2,383.01 / $2,780.18
| Professional | | $2,184.42 | $2,383.01 | $2,780.18 |
- 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
- $2,025.56 / $2,482.30 / $3,194.96
| Professional | | $2,025.56 | $2,482.30 | $3,194.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,942.16 / $2,716.22
| Professional | | $29.27 | $1,942.16 | $2,716.22 |