- 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
- $2,099.41 / $2,380.98 / $2,945.56
| Professional | | $2,099.41 | $2,380.98 | $2,945.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.91 / $3,031.35 / $6,186.50
| Professional | | $2,231.91 | $3,031.35 | $6,186.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,247.09 / $3,648.21 / $4,195.43
| Professional | | $3,247.09 | $3,648.21 | $4,195.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.58 / $2,910.10 / $3,395.11
| Professional | | $2,570.58 | $2,910.10 | $3,395.11 |
- 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
- $2,361.34 / $3,031.35 / $4,231.74
| Professional | | $2,361.34 | $3,031.35 | $4,231.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,276.00 / $3,341.47
| Professional | | $29.27 | $2,276.00 | $3,341.47 |