- 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
- $1,821.31 / $1,821.31 / $1,821.31
| Professional | | $1,821.31 | $1,821.31 | $1,821.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.85 / $2,181.85 / $2,372.06
| Professional | | $2,181.85 | $2,181.85 | $2,372.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.84 / $3,064.11 / $3,788.02
| Professional | | $2,799.84 | $3,064.11 | $3,788.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.03 / $2,094.58 / $2,443.67
| Professional | | $1,920.03 | $2,094.58 | $2,443.67 |
- 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
- $1,780.39 / $2,246.78 / $2,918.31
| Professional | | $1,780.39 | $2,246.78 | $2,918.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,092.69 / $2,981.50
| Professional | | $29.27 | $2,092.69 | $2,981.50 |