- 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
- $2,483.62 / $2,483.62 / $2,483.62
| Professional | | $2,483.62 | $2,483.62 | $2,483.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.15 / $2,621.15 / $3,224.50
| Professional | | $2,621.15 | $2,621.15 | $3,224.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.89 / $3,508.50 / $4,337.39
| Professional | | $3,205.89 | $3,508.50 | $4,337.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.61 / $2,516.30 / $2,935.69
| Professional | | $2,306.61 | $2,516.30 | $2,935.69 |
- 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
- $2,138.86 / $2,761.69 / $3,548.96
| Professional | | $2,138.86 | $2,761.69 | $3,548.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,710.63 / $2,940.34
| Professional | | $29.27 | $2,710.63 | $2,940.34 |