- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.69 / $2,100.00 / $4,011.06
| Professional | | $1,865.69 | $2,100.00 | $4,011.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.11 / $3,248.15 / $3,248.15
| Professional | | $2,326.11 | $3,248.15 | $3,248.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.15 / $2,897.27 / $3,418.78
| Professional | | $2,472.15 | $2,897.27 | $3,418.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,858.37 / $3,118.22 / $3,637.93
| Professional | | $2,858.37 | $3,118.22 | $3,637.93 |
- 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
- $2,589.54 / $3,248.15 / $3,739.50
| Professional | | $2,589.54 | $3,248.15 | $3,739.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,345.41 / $3,504.31
| Professional | | $29.27 | $2,345.41 | $3,504.31 |