- 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
- $2,198.59 / $2,198.59 / $2,526.34
| Professional | | $2,198.59 | $2,198.59 | $2,526.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.62 / $2,973.16 / $2,973.16
| Professional | | $2,524.62 | $2,973.16 | $2,973.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.29 / $3,558.54 / $4,199.08
| Professional | | $3,167.29 | $3,558.54 | $4,199.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.38 / $2,854.24 / $3,329.94
| Professional | | $2,616.38 | $2,854.24 | $3,329.94 |
- 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
- $2,724.14 / $2,973.16 / $3,845.58
| Professional | | $2,724.14 | $2,973.16 | $3,845.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,408.73 / $3,259.34
| Professional | | $29.27 | $2,408.73 | $3,259.34 |