- 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
- $1,747.62 / $2,101.73 / $2,101.73
| Professional | | $1,747.62 | $2,101.73 | $2,101.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.37 / $2,701.79 / $2,901.04
| Professional | | $2,318.37 | $2,701.79 | $2,901.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,124.92 / $3,419.88 / $4,142.91
| Professional | | $3,124.92 | $3,419.88 | $4,142.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.57 / $2,593.71 / $3,026.00
| Professional | | $2,377.57 | $2,593.71 | $3,026.00 |
- 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
- $2,204.66 / $2,717.24 / $3,632.55
| Professional | | $2,204.66 | $2,717.24 | $3,632.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,601.17 / $2,989.78
| Professional | | $29.27 | $2,601.17 | $2,989.78 |