- 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
- $2,475.80 / $2,651.41 / $3,266.30
| Professional | | $2,475.80 | $2,651.41 | $3,266.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.32 / $3,303.49 / $6,358.76
| Professional | | $2,701.32 | $3,303.49 | $6,358.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,583.10 / $4,025.72 / $4,629.58
| Professional | | $3,583.10 | $4,025.72 | $4,629.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.36 / $3,171.35 / $3,699.91
| Professional | | $2,801.36 | $3,171.35 | $3,699.91 |
- 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
- $2,603.65 / $3,454.11 / $4,481.28
| Professional | | $2,603.65 | $3,454.11 | $4,481.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,746.63 / $4,391.64
| Professional | | $29.27 | $2,746.63 | $4,391.64 |