- 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
- $2,527.56 / $2,527.56 / $2,769.35
| Professional | | $2,527.56 | $2,527.56 | $2,769.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.10 / $3,391.15 / $3,391.15
| Professional | | $2,659.10 | $3,391.15 | $3,391.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,811.60 / $4,282.45 / $5,053.29
| Professional | | $3,811.60 | $4,282.45 | $5,053.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.21 / $3,255.50 / $3,798.09
| Professional | | $2,984.21 | $3,255.50 | $3,798.09 |
- 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
- $2,767.18 / $3,391.15 / $4,307.58
| Professional | | $2,767.18 | $3,391.15 | $4,307.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,604.71 / $3,922.38
| Professional | | $29.27 | $2,604.71 | $3,922.38 |