- 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
- $1,983.81 / $1,983.81 / $1,983.81
| Professional | | $1,983.81 | $1,983.81 | $1,983.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,598.81 / $2,598.81 / $2,598.81
| Professional | | $2,598.81 | $2,598.81 | $2,598.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,286.96 / $2,494.86 / $2,910.67
| Professional | | $2,286.96 | $2,494.86 | $2,910.67 |
- 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
- $2,120.63 / $2,749.88 / $3,546.00
| Professional | | $2,120.63 | $2,749.88 | $3,546.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.40 / $2,709.58 / $2,916.24
| Professional | | $367.40 | $2,709.58 | $2,916.24 |