- 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
- $2,156.81 / $2,346.16 / $2,346.16
| Professional | | $2,156.81 | $2,346.16 | $2,346.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.27 / $3,189.76 / $3,189.76
| Professional | | $2,539.27 | $3,189.76 | $3,189.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,408.90 / $3,830.00 / $4,519.39
| Professional | | $3,408.90 | $3,830.00 | $4,519.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,806.99 / $3,062.17 / $3,572.53
| Professional | | $2,806.99 | $3,062.17 | $3,572.53 |
- 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
- $3,022.87 / $3,189.76 / $4,031.94
| Professional | | $3,022.87 | $3,189.76 | $4,031.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,082.83 / $4,343.49
| Professional | | $29.27 | $3,082.83 | $4,343.49 |