- 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
- $1,645.98 / $1,792.97 / $2,221.11
| Professional | | $1,645.98 | $1,792.97 | $2,221.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.52 / $2,244.42 / $4,678.51
| Professional | | $1,855.52 | $2,244.42 | $4,678.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.87 / $2,718.79 / $3,126.61
| Professional | | $2,419.87 | $2,718.79 | $3,126.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.27 / $2,154.65 / $2,513.76
| Professional | | $1,903.27 | $2,154.65 | $2,513.76 |
- 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
- $1,705.92 / $2,244.42 / $3,094.99
| Professional | | $1,705.92 | $2,244.42 | $3,094.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,660.10 / $2,737.83
| Professional | | $29.27 | $1,660.10 | $2,737.83 |