- 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
- $1,396.84 / $1,515.64 / $1,952.92
| Professional | | $1,396.84 | $1,515.64 | $1,952.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.33 / $1,886.01 / $3,495.07
| Professional | | $1,543.33 | $1,886.01 | $3,495.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.82 / $2,267.08 / $2,607.14
| Professional | | $2,017.82 | $2,267.08 | $2,607.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.34 / $1,810.57 / $2,112.33
| Professional | | $1,599.34 | $1,810.57 | $2,112.33 |
- 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
- $1,443.42 / $1,886.01 / $2,752.93
| Professional | | $1,443.42 | $1,886.01 | $2,752.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,483.45 / $2,386.05
| Professional | | $29.27 | $1,483.45 | $2,386.05 |