- 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
- $3,051.57 / $3,051.57 / $3,051.57
| Professional | | $3,051.57 | $3,051.57 | $3,051.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,809.35 / $3,585.23 / $4,302.27
| Professional | | $2,809.35 | $3,585.23 | $4,302.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,887.99 / $4,254.97 / $5,023.51
| Professional | | $3,887.99 | $4,254.97 | $5,023.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.00 / $3,441.82 / $4,015.45
| Professional | | $3,155.00 | $3,441.82 | $4,015.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.54 / $3,585.23 / $4,654.17
| Professional | | $2,925.54 | $3,585.23 | $4,654.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,895.93 / $3,933.82
| Professional | | $29.27 | $2,895.93 | $3,933.82 |