- 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
- $2,291.35 / $2,291.35 / $2,624.04
| Professional | | $2,291.35 | $2,291.35 | $2,624.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.98 / $3,085.25 / $3,086.85
| Professional | | $2,622.98 | $3,085.25 | $3,086.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,288.37 / $3,694.58 / $4,359.60
| Professional | | $3,288.37 | $3,694.58 | $4,359.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.02 / $2,961.84 / $3,455.48
| Professional | | $2,715.02 | $2,961.84 | $3,455.48 |
- 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
- $2,517.56 / $3,085.25 / $3,993.98
| Professional | | $2,517.56 | $3,085.25 | $3,993.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,526.98 / $3,383.95
| Professional | | $29.27 | $2,526.98 | $3,383.95 |