- 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
- $2,773.14 / $2,773.14 / $2,773.14
| Professional | | $2,773.14 | $2,773.14 | $2,773.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.30 / $3,308.45 / $3,970.14
| Professional | | $2,591.30 | $3,308.45 | $3,970.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,563.12 / $3,899.44 / $4,603.76
| Professional | | $3,563.12 | $3,899.44 | $4,603.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,911.44 / $3,176.11 / $3,705.46
| Professional | | $2,911.44 | $3,176.11 | $3,705.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,699.70 / $3,308.45 / $4,284.96
| Professional | | $2,699.70 | $3,308.45 | $4,284.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,669.13 / $3,626.76
| Professional | | $29.27 | $2,669.13 | $3,626.76 |