- 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
- $1,683.50 / $1,863.80 / $2,789.17
| Professional | | $1,683.50 | $1,863.80 | $2,789.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.82 / $2,265.05 / $2,265.05
| Professional | | $1,906.82 | $2,265.05 | $2,265.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.55 / $2,765.50 / $15,461.00
| Professional | | $2,403.55 | $2,765.50 | $15,461.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.24 / $2,174.44 / $2,536.86
| Professional | | $1,993.24 | $2,174.44 | $2,536.86 |
- 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
- $1,848.28 / $2,265.05 / $2,908.86
| Professional | | $1,848.28 | $2,265.05 | $2,908.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.18 / $2,179.05 / $2,915.95
| Professional | | $309.18 | $2,179.05 | $2,915.95 |