- 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
- $2,417.55 / $2,586.30 / $3,239.17
| Professional | | $2,417.55 | $2,586.30 | $3,239.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.71 / $3,476.53 / $6,678.64
| Professional | | $2,606.71 | $3,476.53 | $6,678.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,724.57 / $4,184.67 / $4,812.37
| Professional | | $3,724.57 | $4,184.67 | $4,812.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,948.09 / $3,337.46 / $3,893.71
| Professional | | $2,948.09 | $3,337.46 | $3,893.71 |
- 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
- $2,570.52 / $3,476.53 / $4,751.53
| Professional | | $2,570.52 | $3,476.53 | $4,751.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,870.14 / $4,427.95
| Professional | | $29.27 | $2,870.14 | $4,427.95 |