- 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
- $1,658.91 / $1,773.44 / $2,191.14
| Professional | | $1,658.91 | $1,773.44 | $2,191.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.11 / $2,158.11 / $2,289.28
| Professional | | $2,158.11 | $2,158.11 | $2,289.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.75 / $2,733.52 / $3,379.31
| Professional | | $2,497.75 | $2,733.52 | $3,379.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.14 / $2,071.79 / $2,417.09
| Professional | | $1,899.14 | $2,071.79 | $2,417.09 |
- 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
- $1,761.02 / $2,191.36 / $2,857.92
| Professional | | $1,761.02 | $2,191.36 | $2,857.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,174.46 / $3,168.03
| Professional | | $29.27 | $2,174.46 | $3,168.03 |