- 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
- $1,310.14 / $1,413.23 / $1,807.92
| Professional | | $1,310.14 | $1,413.23 | $1,807.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.34 / $1,861.03 / $3,813.45
| Professional | | $1,444.34 | $1,861.03 | $3,813.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.00 / $2,252.67 / $2,590.57
| Professional | | $2,005.00 | $2,252.67 | $2,590.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.15 / $1,786.58 / $2,084.35
| Professional | | $1,578.15 | $1,786.58 | $2,084.35 |
- 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
- $1,453.19 / $1,889.14 / $2,531.46
| Professional | | $1,453.19 | $1,889.14 | $2,531.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,370.14 / $2,134.60
| Professional | | $29.27 | $1,370.14 | $2,134.60 |