- 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
- $2,234.42 / $2,234.42 / $2,234.42
| Professional | | $2,234.42 | $2,234.42 | $2,234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.46 / $2,861.90 / $3,434.28
| Professional | | $2,240.46 | $2,861.90 | $3,434.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.34 / $3,334.97 / $3,937.34
| Professional | | $3,047.34 | $3,334.97 | $3,937.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.46 / $2,747.42 / $3,205.33
| Professional | | $2,518.46 | $2,747.42 | $3,205.33 |
- 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
- $2,335.31 / $2,861.90 / $3,696.30
| Professional | | $2,335.31 | $2,861.90 | $3,696.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,142.61 / $3,135.90
| Professional | | $29.27 | $2,142.61 | $3,135.90 |