- 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
- $2,526.21 / $2,732.37 / $3,435.17
| Professional | | $2,526.21 | $2,732.37 | $3,435.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.00 / $3,321.63 / $6,988.01
| Professional | | $2,607.00 | $3,321.63 | $6,988.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,731.96 / $4,192.97 / $4,821.92
| Professional | | $3,731.96 | $4,192.97 | $4,821.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.74 / $3,188.76 / $3,720.22
| Professional | | $2,816.74 | $3,188.76 | $3,720.22 |
- 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
- $2,682.93 / $3,496.64 / $4,635.06
| Professional | | $2,682.93 | $3,496.64 | $4,635.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,453.52 / $3,665.84
| Professional | | $29.27 | $2,453.52 | $3,665.84 |