- 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
- $2,462.07 / $2,462.07 / $2,462.07
| Professional | | $2,462.07 | $2,462.07 | $2,462.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.09 / $2,926.51 / $3,511.82
| Professional | | $2,290.09 | $2,926.51 | $3,511.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,112.53 / $3,406.32 / $4,021.57
| Professional | | $3,112.53 | $3,406.32 | $4,021.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.33 / $2,809.45 / $3,277.69
| Professional | | $2,575.33 | $2,809.45 | $3,277.69 |
- 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
- $2,388.03 / $2,926.51 / $3,776.70
| Professional | | $2,388.03 | $2,926.51 | $3,776.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,139.57 / $3,203.00
| Professional | | $29.27 | $2,139.57 | $3,203.00 |