- 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
- $3,340.21 / $3,340.21 / $3,340.21
| Professional | | $3,340.21 | $3,340.21 | $3,340.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,930.63 / $3,930.63 / $4,341.95
| Professional | | $3,930.63 | $3,930.63 | $4,341.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.64 / $5,802.07 / $7,172.80
| Professional | | $5,301.64 | $5,802.07 | $7,172.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,458.95 / $3,773.40 / $4,402.30
| Professional | | $3,458.95 | $3,773.40 | $4,402.30 |
- 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
- $3,207.39 / $4,084.22 / $5,292.17
| Professional | | $3,207.39 | $4,084.22 | $5,292.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.26 / $4,050.79 / $4,359.74
| Professional | | $549.26 | $4,050.79 | $4,359.74 |