- 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
- $1,662.54 / $1,818.21 / $2,723.25
| Professional | | $1,662.54 | $1,818.21 | $2,723.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.72 / $2,204.88 / $4,356.82
| Professional | | $1,865.72 | $2,204.88 | $4,356.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.44 / $2,675.62 / $3,076.96
| Professional | | $2,381.44 | $2,675.62 | $3,076.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.73 / $2,116.67 / $2,469.46
| Professional | | $1,869.73 | $2,116.67 | $2,469.46 |
- 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
- $1,672.44 / $2,204.88 / $2,956.59
| Professional | | $1,672.44 | $2,204.88 | $2,956.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,806.84 / $2,908.82
| Professional | | $29.27 | $1,806.84 | $2,908.82 |