- 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
- $3,180.29 / $3,180.29 / $3,180.29
| Professional | | $3,180.29 | $3,180.29 | $3,180.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.78 / $3,903.78 / $3,987.44
| Professional | | $3,903.78 | $3,903.78 | $3,987.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,726.99 / $5,173.17 / $6,395.33
| Professional | | $4,726.99 | $5,173.17 | $6,395.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.32 / $3,747.62 / $4,372.22
| Professional | | $3,435.32 | $3,747.62 | $4,372.22 |
- 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
- $3,185.48 / $4,079.09 / $5,283.11
| Professional | | $3,185.48 | $4,079.09 | $5,283.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.08 / $2,901.05 / $4,334.51
| Professional | | $546.08 | $2,901.05 | $4,334.51 |