- 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
- $1,548.76 / $1,852.03 / $1,852.03
| Professional | | $1,548.76 | $1,852.03 | $1,852.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.10 / $2,377.78 / $2,538.17
| Professional | | $2,052.10 | $2,377.78 | $2,538.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.71 / $3,136.57 / $3,701.15
| Professional | | $2,791.71 | $3,136.57 | $3,701.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.44 / $2,282.66 / $2,663.11
| Professional | | $2,092.44 | $2,282.66 | $2,663.11 |
- 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
- $1,940.26 / $2,498.02 / $3,165.05
| Professional | | $1,940.26 | $2,498.02 | $3,165.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.50 / $2,437.46 / $3,605.34
| Professional | | $330.50 | $2,437.46 | $3,605.34 |