- 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
- $2,321.75 / $2,742.16 / $2,742.16
| Professional | | $2,321.75 | $2,742.16 | $2,742.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.48 / $3,663.21 / $3,663.21
| Professional | | $3,002.48 | $3,663.21 | $3,663.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,925.33 / $4,410.22 / $5,204.06
| Professional | | $3,925.33 | $4,410.22 | $5,204.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,223.63 / $3,516.68 / $4,102.80
| Professional | | $3,223.63 | $3,516.68 | $4,102.80 |
- 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
- $2,989.18 / $3,663.21 / $4,803.09
| Professional | | $2,989.18 | $3,663.21 | $4,803.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,597.60 / $4,049.91
| Professional | | $29.27 | $3,597.60 | $4,049.91 |