- 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
- $2,455.39 / $2,455.39 / $2,907.85
| Professional | | $2,455.39 | $2,455.39 | $2,907.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,877.87 / $3,439.09 / $3,439.09
| Professional | | $2,877.87 | $3,439.09 | $3,439.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,716.74 / $4,175.85 / $4,927.51
| Professional | | $3,716.74 | $4,175.85 | $4,927.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,026.40 / $3,301.52 / $3,851.78
| Professional | | $3,026.40 | $3,301.52 | $3,851.78 |
- 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
- $2,806.30 / $3,439.09 / $4,464.75
| Professional | | $2,806.30 | $3,439.09 | $4,464.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,539.88 / $3,824.76
| Professional | | $29.27 | $2,539.88 | $3,824.76 |