- 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
- $1,842.51 / $2,057.67 / $2,557.88
| Professional | | $1,842.51 | $2,057.67 | $2,557.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.67 / $2,559.86 / $5,351.11
| Professional | | $2,128.67 | $2,559.86 | $5,351.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,767.04 / $3,108.85 / $3,575.18
| Professional | | $2,767.04 | $3,108.85 | $3,575.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.76 / $2,457.46 / $2,867.05
| Professional | | $2,170.76 | $2,457.46 | $2,867.05 |
- 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
- $2,043.36 / $2,559.86 / $3,784.05
| Professional | | $2,043.36 | $2,559.86 | $3,784.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,939.34 / $3,130.78
| Professional | | $29.27 | $1,939.34 | $3,130.78 |