- 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
- $2,894.73 / $4,288.06 / $10,589.00
| Professional | | $2,894.73 | $4,288.06 | $10,589.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.12 / $3,503.15 / $4,203.78
| Professional | | $2,746.12 | $3,503.15 | $4,203.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,773.16 / $4,129.32 / $4,875.14
| Professional | | $3,773.16 | $4,129.32 | $4,875.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.77 / $3,363.02 / $3,923.53
| Professional | | $3,082.77 | $3,363.02 | $3,923.53 |
- 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
- $2,858.57 / $3,503.15 / $4,551.62
| Professional | | $2,858.57 | $3,503.15 | $4,551.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,773.88 / $3,846.36
| Professional | | $29.27 | $2,773.88 | $3,846.36 |