- 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
- $1,863.77 / $1,951.12 / $1,951.12
| Professional | | $1,863.77 | $1,951.12 | $1,951.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.49 / $2,210.65 / $2,230.21
| Professional | | $1,797.49 | $2,210.65 | $2,230.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.67 / $2,910.71 / $3,434.64
| Professional | | $2,590.67 | $2,910.71 | $3,434.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.37 / $2,122.21 / $2,475.92
| Professional | | $1,945.37 | $2,122.21 | $2,475.92 |
- 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
- $1,803.89 / $2,223.56 / $2,898.42
| Professional | | $1,803.89 | $2,223.56 | $2,898.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,804.76 / $2,858.15
| Professional | | $29.27 | $1,804.76 | $2,858.15 |