- 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
- $2,280.27 / $2,522.10 / $2,522.10
| Professional | | $2,280.27 | $2,522.10 | $2,522.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,029.81 / $3,513.59 / $3,513.59
| Professional | | $3,029.81 | $3,513.59 | $3,513.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,995.20 / $4,488.72 / $5,296.69
| Professional | | $3,995.20 | $4,488.72 | $5,296.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,091.96 / $3,373.04 / $3,935.22
| Professional | | $3,091.96 | $3,373.04 | $3,935.22 |
- 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
- $2,867.09 / $3,513.59 / $4,715.30
| Professional | | $2,867.09 | $3,513.59 | $4,715.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,869.31 / $3,893.62
| Professional | | $29.27 | $2,869.31 | $3,893.62 |