- 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
- $2,272.86 / $2,429.89 / $2,859.75
| Professional | | $2,272.86 | $2,429.89 | $2,859.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.95 / $2,774.95 / $3,149.69
| Professional | | $2,774.95 | $2,774.95 | $3,149.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,277.10 / $3,586.43 / $4,433.72
| Professional | | $3,277.10 | $3,586.43 | $4,433.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.96 / $2,663.95 / $3,107.94
| Professional | | $2,441.96 | $2,663.95 | $3,107.94 |
- 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
- $2,264.36 / $2,874.64 / $3,726.51
| Professional | | $2,264.36 | $2,874.64 | $3,726.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,856.54 / $4,185.01
| Professional | | $29.27 | $2,856.54 | $4,185.01 |