- 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
- $2,496.48 / $2,663.72 / $3,288.18
| Professional | | $2,496.48 | $2,663.72 | $3,288.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.56 / $3,365.01 / $6,337.50
| Professional | | $2,724.56 | $3,365.01 | $6,337.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,694.92 / $4,151.35 / $4,774.05
| Professional | | $3,694.92 | $4,151.35 | $4,774.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,918.34 / $3,303.78 / $3,854.41
| Professional | | $2,918.34 | $3,303.78 | $3,854.41 |
- 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
- $2,532.64 / $3,441.44 / $4,500.51
| Professional | | $2,532.64 | $3,441.44 | $4,500.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,524.96 / $4,144.58
| Professional | | $29.27 | $2,524.96 | $4,144.58 |