- 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
- $1,693.17 / $1,843.05 / $2,206.12
| Professional | | $1,693.17 | $1,843.05 | $2,206.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.63 / $2,271.75 / $4,239.09
| Professional | | $1,883.63 | $2,271.75 | $4,239.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.11 / $2,744.91 / $3,156.65
| Professional | | $2,443.11 | $2,744.91 | $3,156.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.44 / $2,180.88 / $2,544.36
| Professional | | $1,926.44 | $2,180.88 | $2,544.36 |
- 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
- $1,760.78 / $2,271.75 / $3,273.43
| Professional | | $1,760.78 | $2,271.75 | $3,273.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,838.41 / $2,972.76
| Professional | | $29.27 | $1,838.41 | $2,972.76 |