- 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
- $1,685.78 / $1,685.78 / $1,685.78
| Professional | | $1,685.78 | $1,685.78 | $1,685.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.23 / $2,209.23 / $2,209.23
| Professional | | $2,209.23 | $2,209.23 | $2,209.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.12 / $2,120.86 / $2,474.33
| Professional | | $1,944.12 | $2,120.86 | $2,474.33 |
- 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
- $1,802.73 / $2,327.94 / $2,999.21
| Professional | | $1,802.73 | $2,327.94 | $2,999.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.82 / $2,292.33 / $2,467.17
| Professional | | $310.82 | $2,292.33 | $2,467.17 |