- 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
- $2,471.46 / $2,737.82 / $4,045.41
| Professional | | $2,471.46 | $2,737.82 | $4,045.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.04 / $3,965.48 / $8,518.87
| Professional | | $2,666.04 | $3,965.48 | $8,518.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,368.35 / $4,907.97 / $5,644.18
| Professional | | $4,368.35 | $4,907.97 | $5,644.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,362.72 / $3,806.86 / $4,441.33
| Professional | | $3,362.72 | $3,806.86 | $4,441.33 |
- 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
- $2,936.84 / $3,965.48 / $5,611.07
| Professional | | $2,936.84 | $3,965.48 | $5,611.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,985.17 / $4,460.20
| Professional | | $29.27 | $2,985.17 | $4,460.20 |