- 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
- $2,050.59 / $2,166.69 / $2,743.70
| Professional | | $2,050.59 | $2,166.69 | $2,743.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.95 / $3,398.55 / $3,398.55
| Professional | | $2,721.95 | $3,398.55 | $3,398.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,671.33 / $4,124.85 / $4,867.32
| Professional | | $3,671.33 | $4,124.85 | $4,867.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,990.72 / $3,262.61 / $3,806.38
| Professional | | $2,990.72 | $3,262.61 | $3,806.38 |
- 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
- $2,773.22 / $3,398.55 / $4,407.68
| Professional | | $2,773.22 | $3,398.55 | $4,407.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,508.85 / $3,778.04
| Professional | | $29.27 | $2,508.85 | $3,778.04 |