- 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
- $1,519.47 / $1,519.47 / $1,519.47
| Professional | | $1,519.47 | $1,519.47 | $1,519.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.83 / $1,819.83 / $1,969.24
| Professional | | $1,819.83 | $1,819.83 | $1,969.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.08 / $2,314.73 / $2,861.58
| Professional | | $2,115.08 | $2,314.73 | $2,861.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.45 / $1,747.03 / $2,038.20
| Professional | | $1,601.45 | $1,747.03 | $2,038.20 |
- 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
- $1,484.98 / $1,860.13 / $2,419.98
| Professional | | $1,484.98 | $1,860.13 | $2,419.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,770.86 / $2,596.76
| Professional | | $29.27 | $1,770.86 | $2,596.76 |