- 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
- $1,845.34 / $1,915.12 / $1,915.12
| Professional | | $1,845.34 | $1,915.12 | $1,915.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.97 / $2,195.48 / $2,195.48
| Professional | | $1,778.97 | $2,195.48 | $2,195.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.65 / $2,839.89 / $3,351.07
| Professional | | $2,527.65 | $2,839.89 | $3,351.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.03 / $2,107.67 / $2,458.94
| Professional | | $1,932.03 | $2,107.67 | $2,458.94 |
- 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
- $1,791.52 / $2,197.80 / $2,866.68
| Professional | | $1,791.52 | $2,197.80 | $2,866.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,867.10 / $2,931.31
| Professional | | $29.27 | $1,867.10 | $2,931.31 |