- 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
- $1,984.43 / $2,219.31 / $2,725.66
| Professional | | $1,984.43 | $2,219.31 | $2,725.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,144.89 / $2,750.08 / $5,718.53
| Professional | | $2,144.89 | $2,750.08 | $5,718.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.65 / $3,344.35 / $3,846.00
| Professional | | $2,976.65 | $3,344.35 | $3,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.06 / $2,640.07 / $3,080.08
| Professional | | $2,332.06 | $2,640.07 | $3,080.08 |
- 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
- $2,189.19 / $2,750.08 / $4,026.18
| Professional | | $2,189.19 | $2,750.08 | $4,026.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,034.13 / $3,178.65
| Professional | | $29.27 | $2,034.13 | $3,178.65 |