- 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
- $1,889.67 / $2,031.86 / $2,689.24
| Professional | | $1,889.67 | $2,031.86 | $2,689.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.81 / $2,777.94 / $5,642.41
| Professional | | $2,031.81 | $2,777.94 | $5,642.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.53 / $3,337.48 / $3,838.10
| Professional | | $2,970.53 | $3,337.48 | $3,838.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.69 / $2,666.82 / $3,111.29
| Professional | | $2,355.69 | $2,666.82 | $3,111.29 |
- 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
- $2,072.65 / $2,777.94 / $3,774.41
| Professional | | $2,072.65 | $2,777.94 | $3,774.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,029.95 / $3,056.87
| Professional | | $29.27 | $2,029.95 | $3,056.87 |