- 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
- $2,532.92 / $2,895.80 / $3,610.49
| Professional | | $2,532.92 | $2,895.80 | $3,610.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.98 / $3,591.69 / $7,546.37
| Professional | | $2,441.98 | $3,591.69 | $7,546.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,884.11 / $4,363.91 / $5,018.50
| Professional | | $3,884.11 | $4,363.91 | $5,018.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.75 / $3,448.02 / $4,022.69
| Professional | | $3,045.75 | $3,448.02 | $4,022.69 |
- 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
- $2,883.63 / $3,591.69 / $5,337.58
| Professional | | $2,883.63 | $3,591.69 | $5,337.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,492.21 / $3,996.99
| Professional | | $29.27 | $2,492.21 | $3,996.99 |