- 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
- $2,946.27 / $2,946.27 / $2,946.27
| Professional | | $2,946.27 | $2,946.27 | $2,946.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,529.03 / $3,529.03 / $3,844.06
| Professional | | $3,529.03 | $3,529.03 | $3,844.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,165.49 / $4,558.68 / $5,635.67
| Professional | | $4,165.49 | $4,558.68 | $5,635.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,105.54 / $3,387.86 / $3,952.51
| Professional | | $3,105.54 | $3,387.86 | $3,952.51 |
- 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
- $2,879.68 / $3,608.53 / $4,740.81
| Professional | | $2,879.68 | $3,608.53 | $4,740.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,619.14 / $3,913.30
| Professional | | $29.27 | $2,619.14 | $3,913.30 |