- 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
- $2,536.11 / $2,536.11 / $2,536.11
| Professional | | $2,536.11 | $2,536.11 | $2,536.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.13 / $3,012.13 / $3,296.00
| Professional | | $3,012.13 | $3,012.13 | $3,296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,535.15 / $3,868.84 / $4,782.85
| Professional | | $3,535.15 | $3,868.84 | $4,782.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.67 / $2,891.64 / $3,373.58
| Professional | | $2,650.67 | $2,891.64 | $3,373.58 |
- 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
- $2,457.89 / $3,107.10 / $4,030.11
| Professional | | $2,457.89 | $3,107.10 | $4,030.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,464.42 / $3,553.68
| Professional | | $29.27 | $2,464.42 | $3,553.68 |