- 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
- $2,088.76 / $2,088.76 / $2,382.39
| Professional | | $2,088.76 | $2,088.76 | $2,382.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.65 / $2,807.63 / $2,807.63
| Professional | | $2,379.65 | $2,807.63 | $2,807.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,989.45 / $3,358.74 / $3,963.31
| Professional | | $2,989.45 | $3,358.74 | $3,963.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.71 / $2,695.32 / $3,144.54
| Professional | | $2,470.71 | $2,695.32 | $3,144.54 |
- 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
- $2,291.02 / $2,807.63 / $3,626.06
| Professional | | $2,291.02 | $2,807.63 | $3,626.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,297.88 / $3,076.34
| Professional | | $29.27 | $2,297.88 | $3,076.34 |