- 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
- $2,547.34 / $3,813.64 / $10,885.00
| Professional | | $2,547.34 | $3,813.64 | $10,885.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.85 / $3,108.10 / $3,729.72
| Professional | | $2,432.85 | $3,108.10 | $3,729.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.96 / $3,692.43 / $4,359.35
| Professional | | $3,373.96 | $3,692.43 | $4,359.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.13 / $2,983.78 / $3,481.07
| Professional | | $2,735.13 | $2,983.78 | $3,481.07 |
- 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
- $2,536.21 / $3,108.10 / $4,016.93
| Professional | | $2,536.21 | $3,108.10 | $4,016.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,573.66 / $3,404.61
| Professional | | $29.27 | $2,573.66 | $3,404.61 |