- 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
- $1,310.20 / $1,399.93 / $1,801.35
| Professional | | $1,310.20 | $1,399.93 | $1,801.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.48 / $1,910.24 / $3,552.13
| Professional | | $1,482.48 | $1,910.24 | $3,552.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.16 / $2,533.73 / $2,913.80
| Professional | | $2,255.16 | $2,533.73 | $2,913.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.99 / $1,622.26 / $1,892.63
| Professional | | $1,432.99 | $1,622.26 | $1,892.63 |
- 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
- $1,378.92 / $1,760.41 / $2,523.25
| Professional | | $1,378.92 | $1,760.41 | $2,523.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.31 / $1,250.08 / $1,867.78
| Professional | | $235.31 | $1,250.08 | $1,867.78 |