- 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
- $2,121.07 / $2,121.07 / $2,121.07
| Professional | | $2,121.07 | $2,121.07 | $2,121.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,644.71 / $2,644.71 / $2,648.21
| Professional | | $2,644.71 | $2,644.71 | $2,648.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.20 / $3,662.67 / $4,306.82
| Professional | | $2,961.20 | $3,662.67 | $4,306.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.35 / $2,538.92 / $2,962.08
| Professional | | $2,327.35 | $2,538.92 | $2,962.08 |
- 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
- $2,158.09 / $2,751.74 / $3,563.06
| Professional | | $2,158.09 | $2,751.74 | $3,563.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,425.05 / $3,517.11
| Professional | | $29.27 | $2,425.05 | $3,517.11 |