- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $6,966.00 / $8,499.00
| Facility | | $2,747.00 | $6,966.00 | $8,499.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.97 / $2,044.97 / $2,044.97
| Professional | | $2,044.97 | $2,044.97 | $2,044.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.37 / $2,762.73 / $3,315.27
| Professional | | $2,160.37 | $2,762.73 | $3,315.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.92 / $3,227.82 / $3,753.28
| Professional | | $2,872.92 | $3,227.82 | $3,753.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.19 / $2,652.22 / $3,094.25
| Professional | | $2,431.19 | $2,652.22 | $3,094.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.38 / $2,762.73 / $3,564.63
| Professional | | $2,254.38 | $2,762.73 | $3,564.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.61 / $2,283.26 / $3,020.88
| Professional | | $377.61 | $2,283.26 | $3,020.88 |