- 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
- $2,056.39 / $2,056.39 / $2,056.39
| Professional | | $2,056.39 | $2,056.39 | $2,056.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.36 / $2,545.98 / $3,055.17
| Professional | | $2,062.36 | $2,545.98 | $3,055.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.86 / $3,066.32 / $3,620.17
| Professional | | $2,801.86 | $3,066.32 | $3,620.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.46 / $2,444.14 / $2,851.49
| Professional | | $2,240.46 | $2,444.14 | $2,851.49 |
- 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
- $2,077.52 / $2,545.98 / $3,393.02
| Professional | | $2,077.52 | $2,545.98 | $3,393.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,961.43 / $2,883.29
| Professional | | $29.27 | $1,961.43 | $2,883.29 |