- 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
- $2,018.51 / $2,018.51 / $2,018.51
| Professional | | $2,018.51 | $2,018.51 | $2,018.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.54 / $2,776.13 / $3,331.35
| Professional | | $2,168.54 | $2,776.13 | $3,331.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.69 / $3,221.56 / $3,803.43
| Professional | | $2,943.69 | $3,221.56 | $3,803.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.98 / $2,665.08 / $3,109.26
| Professional | | $2,442.98 | $2,665.08 | $3,109.26 |
- 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
- $2,033.57 / $2,776.13 / $3,565.37
| Professional | | $2,033.57 | $2,776.13 | $3,565.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.66 / $2,463.26 / $3,029.26
| Professional | | $378.66 | $2,463.26 | $3,029.26 |