- 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
- $2,484.19 / $2,705.83 / $3,363.16
| Professional | | $2,484.19 | $2,705.83 | $3,363.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,760.54 / $3,383.01 / $7,087.54
| Professional | | $2,760.54 | $3,383.01 | $7,087.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,648.78 / $4,099.51 / $4,714.43
| Professional | | $3,648.78 | $4,099.51 | $4,714.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,868.79 / $3,247.69 / $3,788.97
| Professional | | $2,868.79 | $3,247.69 | $3,788.97 |
- 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
- $2,707.26 / $3,383.01 / $4,682.30
| Professional | | $2,707.26 | $3,383.01 | $4,682.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,493.44 / $3,958.83
| Professional | | $29.27 | $2,493.44 | $3,958.83 |