- 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
- $1,932.32 / $2,126.44 / $2,629.47
| Professional | | $1,932.32 | $2,126.44 | $2,629.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.73 / $2,679.26 / $5,560.85
| Professional | | $2,114.73 | $2,679.26 | $5,560.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,892.88 / $3,250.24 / $3,737.78
| Professional | | $2,892.88 | $3,250.24 | $3,737.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.01 / $2,572.09 / $3,000.77
| Professional | | $2,272.01 | $2,572.09 | $3,000.77 |
- 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
- $2,128.13 / $2,719.28 / $3,678.84
| Professional | | $2,128.13 | $2,719.28 | $3,678.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.12 / $1,976.89 / $2,976.96
| Professional | | $372.12 | $1,976.89 | $2,976.96 |