- 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
- $1,552.99 / $1,711.90 / $2,128.78
| Professional | | $1,552.99 | $1,711.90 | $2,128.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.95 / $2,138.42 / $4,456.04
| Professional | | $1,744.95 | $2,138.42 | $4,456.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.77 / $2,588.36 / $2,976.61
| Professional | | $2,303.77 | $2,588.36 | $2,976.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.38 / $2,052.89 / $2,395.04
| Professional | | $1,813.38 | $2,052.89 | $2,395.04 |
- 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
- $1,706.90 / $2,232.76 / $2,947.25
| Professional | | $1,706.90 | $2,232.76 | $2,947.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,574.32 / $2,523.00
| Professional | | $29.27 | $1,574.32 | $2,523.00 |