- 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
- $2,917.73 / $3,110.21 / $4,507.29
| Professional | | $2,917.73 | $3,110.21 | $4,507.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,709.90 / $3,709.90 / $4,046.59
| Professional | | $3,709.90 | $3,709.90 | $4,046.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,390.85 / $4,805.31 / $5,940.56
| Professional | | $4,390.85 | $4,805.31 | $5,940.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.71 / $3,561.50 / $4,155.09
| Professional | | $3,264.71 | $3,561.50 | $4,155.09 |
- 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
- $3,027.28 / $3,709.90 / $4,982.76
| Professional | | $3,027.28 | $3,709.90 | $4,982.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,054.27 / $4,508.81
| Professional | | $29.27 | $3,054.27 | $4,508.81 |