- 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
- $1,779.01 / $1,899.14 / $7,034.43
| Professional | | $1,779.01 | $1,899.14 | $7,034.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.98 / $2,327.98 / $2,477.46
| Professional | | $2,327.98 | $2,327.98 | $2,477.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.65 / $2,969.80 / $3,671.41
| Professional | | $2,713.65 | $2,969.80 | $3,671.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.62 / $2,234.86 / $2,607.33
| Professional | | $2,048.62 | $2,234.86 | $2,607.33 |
- 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
- $1,899.63 / $2,386.36 / $3,102.90
| Professional | | $1,899.63 | $2,386.36 | $3,102.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,275.92 / $3,386.58
| Professional | | $29.27 | $2,275.92 | $3,386.58 |