- 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
- $1,986.35 / $2,113.94 / $2,585.26
| Professional | | $1,986.35 | $2,113.94 | $2,585.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.05 / $2,742.89 / $5,023.93
| Professional | | $2,207.05 | $2,742.89 | $5,023.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.86 / $3,303.02 / $3,798.47
| Professional | | $2,939.86 | $3,303.02 | $3,798.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.96 / $2,633.17 / $3,072.03
| Professional | | $2,325.96 | $2,633.17 | $3,072.03 |
- 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
- $2,026.14 / $2,742.89 / $3,799.32
| Professional | | $2,026.14 | $2,742.89 | $3,799.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,008.99 / $3,574.58
| Professional | | $29.27 | $2,008.99 | $3,574.58 |