- 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
- $2,328.04 / $2,328.04 / $2,544.42
| Professional | | $2,328.04 | $2,328.04 | $2,544.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.44 / $3,016.73 / $3,016.73
| Professional | | $2,451.44 | $3,016.73 | $3,016.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.18 / $3,626.96 / $4,279.81
| Professional | | $3,228.18 | $3,626.96 | $4,279.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,654.72 / $2,896.06 / $3,378.73
| Professional | | $2,654.72 | $2,896.06 | $3,378.73 |
- 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
- $2,461.65 / $3,016.73 / $3,900.20
| Professional | | $2,461.65 | $3,016.73 | $3,900.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,642.78 / $3,322.01
| Professional | | $29.27 | $2,642.78 | $3,322.01 |