- 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
- $2,258.46 / $2,447.58 / $3,061.56
| Professional | | $2,258.46 | $2,447.58 | $3,061.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.38 / $3,047.25 / $6,225.75
| Professional | | $2,532.38 | $3,047.25 | $6,225.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,292.93 / $3,699.70 / $4,254.66
| Professional | | $3,292.93 | $3,699.70 | $4,254.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,584.07 / $2,925.36 / $3,412.92
| Professional | | $2,584.07 | $2,925.36 | $3,412.92 |
- 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
- $2,415.58 / $3,047.25 / $4,197.85
| Professional | | $2,415.58 | $3,047.25 | $4,197.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,418.65 / $3,995.23
| Professional | | $29.27 | $2,418.65 | $3,995.23 |