- 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
- $3,046.77 / $3,046.77 / $3,046.77
| Professional | | $3,046.77 | $3,046.77 | $3,046.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,810.06 / $3,585.63 / $4,302.75
| Professional | | $2,810.06 | $3,585.63 | $4,302.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,885.38 / $4,252.12 / $5,020.14
| Professional | | $3,885.38 | $4,252.12 | $5,020.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.35 / $3,442.20 / $4,015.90
| Professional | | $3,155.35 | $3,442.20 | $4,015.90 |
- 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
- $2,925.87 / $3,585.63 / $4,655.34
| Professional | | $2,925.87 | $3,585.63 | $4,655.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,920.84 / $3,934.77
| Professional | | $29.27 | $2,920.84 | $3,934.77 |