- 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
- $1,413.98 / $1,554.73 / $2,366.67
| Professional | | $1,413.98 | $1,554.73 | $2,366.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.55 / $1,923.70 / $3,964.09
| Professional | | $1,573.55 | $1,923.70 | $3,964.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.69 / $2,320.86 / $2,668.99
| Professional | | $2,065.69 | $2,320.86 | $2,668.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.30 / $1,846.75 / $2,154.54
| Professional | | $1,631.30 | $1,846.75 | $2,154.54 |
- 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
- $1,511.97 / $1,997.66 / $3,118.16
| Professional | | $1,511.97 | $1,997.66 | $3,118.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,499.97 / $2,395.27
| Professional | | $29.27 | $1,499.97 | $2,395.27 |