- 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
- $2,225.25 / $2,378.69 / $2,378.69
| Professional | | $2,225.25 | $2,378.69 | $2,378.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,085.85 / $3,085.85 / $3,611.64
| Professional | | $3,085.85 | $3,085.85 | $3,611.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,925.41 / $4,295.93 / $5,310.85
| Professional | | $3,925.41 | $4,295.93 | $5,310.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,178.24 / $3,467.17 / $4,045.03
| Professional | | $3,178.24 | $3,467.17 | $4,045.03 |
- 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
- $2,947.10 / $3,611.64 / $4,862.07
| Professional | | $2,947.10 | $3,611.64 | $4,862.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,987.36 / $4,379.58
| Professional | | $29.27 | $2,987.36 | $4,379.58 |