- 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
- $2,533.21 / $2,769.42 / $3,462.68
| Professional | | $2,533.21 | $2,769.42 | $3,462.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,864.64 / $3,447.63 / $7,215.74
| Professional | | $2,864.64 | $3,447.63 | $7,215.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.60 / $4,194.81 / $4,824.03
| Professional | | $3,733.60 | $4,194.81 | $4,824.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,923.59 / $3,309.72 / $3,861.34
| Professional | | $2,923.59 | $3,309.72 | $3,861.34 |
- 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
- $2,632.82 / $3,447.63 / $4,759.18
| Professional | | $2,632.82 | $3,447.63 | $4,759.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,694.64 / $4,330.54
| Professional | | $29.27 | $2,694.64 | $4,330.54 |