- 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
- $2,293.23 / $2,532.62 / $3,748.32
| Professional | | $2,293.23 | $2,532.62 | $3,748.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,598.57 / $3,057.43 / $3,083.11
| Professional | | $2,598.57 | $3,057.43 | $3,083.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,324.33 / $3,734.99 / $4,407.29
| Professional | | $3,324.33 | $3,734.99 | $4,407.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.53 / $2,935.13 / $3,424.32
| Professional | | $2,690.53 | $2,935.13 | $3,424.32 |
- 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
- $2,494.86 / $3,057.43 / $3,957.87
| Professional | | $2,494.86 | $3,057.43 | $3,957.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,524.32 / $3,352.45
| Professional | | $29.27 | $2,524.32 | $3,352.45 |