- 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
- $2,829.93 / $3,057.63 / $3,716.02
| Professional | | $2,829.93 | $3,057.63 | $3,716.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,112.81 / $3,878.94 / $7,817.60
| Professional | | $3,112.81 | $3,878.94 | $7,817.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.71 / $5,028.54 / $5,265.48
| Professional | | $4,677.71 | $5,028.54 | $5,265.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.39 / $3,595.91 / $4,195.22
| Professional | | $3,176.39 | $3,595.91 | $4,195.22 |
- 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
- $3,056.52 / $3,882.70 / $5,165.64
| Professional | | $3,056.52 | $3,882.70 | $5,165.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.64 / $3,695.33 / $4,149.14
| Professional | | $518.64 | $3,695.33 | $4,149.14 |