- 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
- $1,556.81 / $1,712.34 / $2,128.53
| Professional | | $1,556.81 | $1,712.34 | $2,128.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.50 / $2,167.15 / $4,486.80
| Professional | | $1,781.50 | $2,167.15 | $4,486.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.34 / $2,618.21 / $3,010.94
| Professional | | $2,330.34 | $2,618.21 | $3,010.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.74 / $2,080.46 / $2,427.21
| Professional | | $1,837.74 | $2,080.46 | $2,427.21 |
- 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
- $1,719.31 / $2,167.15 / $3,012.73
| Professional | | $1,719.31 | $2,167.15 | $3,012.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,635.27 / $2,627.78
| Professional | | $29.27 | $1,635.27 | $2,627.78 |