- 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
- $2,586.17 / $2,586.17 / $2,750.95
| Professional | | $2,586.17 | $2,586.17 | $2,750.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.94 / $3,633.66 / $3,633.66
| Professional | | $2,686.94 | $3,633.66 | $3,633.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,512.29 / $3,946.16 / $4,656.47
| Professional | | $3,512.29 | $3,946.16 | $4,656.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,197.62 / $3,488.32 / $4,069.70
| Professional | | $3,197.62 | $3,488.32 | $4,069.70 |
- 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
- $2,965.07 / $3,633.66 / $4,219.74
| Professional | | $2,965.07 | $3,633.66 | $4,219.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,691.99 / $3,571.61
| Professional | | $29.27 | $2,691.99 | $3,571.61 |