- 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
- $2,764.29 / $2,764.29 / $2,764.29
| Professional | | $2,764.29 | $2,764.29 | $2,764.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,326.23 / $3,326.23 / $3,598.57
| Professional | | $3,326.23 | $3,326.23 | $3,598.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,877.48 / $4,243.47 / $5,246.00
| Professional | | $3,877.48 | $4,243.47 | $5,246.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,927.08 / $3,193.18 / $3,725.37
| Professional | | $2,927.08 | $3,193.18 | $3,725.37 |
- 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
- $2,714.20 / $3,426.35 / $4,448.42
| Professional | | $2,714.20 | $3,426.35 | $4,448.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,706.48 / $3,960.47
| Professional | | $29.27 | $2,706.48 | $3,960.47 |