- 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
- $1,768.78 / $1,793.44 / $1,793.44
| Professional | | $1,768.78 | $1,793.44 | $1,793.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.87 / $2,148.21 / $2,160.11
| Professional | | $1,740.87 | $2,148.21 | $2,160.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.16 / $2,828.10 / $3,337.16
| Professional | | $2,517.16 | $2,828.10 | $3,337.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.43 / $2,062.28 / $2,406.00
| Professional | | $1,890.43 | $2,062.28 | $2,406.00 |
- 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
- $1,752.94 / $2,150.09 / $2,805.00
| Professional | | $1,752.94 | $2,150.09 | $2,805.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,543.60 / $2,848.36
| Professional | | $29.27 | $1,543.60 | $2,848.36 |