- 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
- $1,513.11 / $1,763.64 / $1,763.64
| Professional | | $1,513.11 | $1,763.64 | $1,763.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.31 / $2,171.67 / $2,245.12
| Professional | | $1,787.31 | $2,171.67 | $2,245.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.86 / $2,640.14 / $3,115.37
| Professional | | $2,349.86 | $2,640.14 | $3,115.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.07 / $2,084.81 / $2,432.28
| Professional | | $1,911.07 | $2,084.81 | $2,432.28 |
- 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
- $1,772.09 / $2,171.67 / $2,802.63
| Professional | | $1,772.09 | $2,171.67 | $2,802.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,118.44 / $3,042.03
| Professional | | $29.27 | $2,118.44 | $3,042.03 |