- 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
- $2,160.69 / $2,263.73 / $2,263.73
| Professional | | $2,160.69 | $2,263.73 | $2,263.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.37 / $2,568.34 / $2,586.67
| Professional | | $2,083.37 | $2,568.34 | $2,586.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.74 / $3,383.78 / $3,992.86
| Professional | | $3,011.74 | $3,383.78 | $3,992.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.14 / $2,465.60 / $2,876.54
| Professional | | $2,260.14 | $2,465.60 | $2,876.54 |
- 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
- $2,095.76 / $2,574.02 / $3,356.49
| Professional | | $2,095.76 | $2,574.02 | $3,356.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,077.28 / $3,291.65
| Professional | | $29.27 | $2,077.28 | $3,291.65 |