- 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
- $1,705.20 / $1,856.42 / $2,275.14
| Professional | | $1,705.20 | $1,856.42 | $2,275.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.21 / $2,287.36 / $4,267.41
| Professional | | $1,939.21 | $2,287.36 | $4,267.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.21 / $2,760.74 / $3,174.85
| Professional | | $2,457.21 | $2,760.74 | $3,174.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.68 / $2,195.87 / $2,561.85
| Professional | | $1,939.68 | $2,195.87 | $2,561.85 |
- 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
- $1,810.80 / $2,287.36 / $3,062.04
| Professional | | $1,810.80 | $2,287.36 | $3,062.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,841.99 / $2,972.87
| Professional | | $29.27 | $1,841.99 | $2,972.87 |