- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $4,456.00 / $5,299.00
| Facility | | $1,758.00 | $4,456.00 | $5,299.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.99 / $1,999.12 / $2,606.44
| Professional | | $1,870.99 | $1,999.12 | $2,606.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.93 / $2,654.09 / $5,525.15
| Professional | | $2,005.93 | $2,654.09 | $5,525.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.23 / $3,224.79 / $3,708.51
| Professional | | $2,870.23 | $3,224.79 | $3,708.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.67 / $2,547.92 / $2,972.58
| Professional | | $2,250.67 | $2,547.92 | $2,972.58 |
- 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
- $2,111.56 / $2,654.09 / $3,698.16
| Professional | | $2,111.56 | $2,654.09 | $3,698.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.21 / $2,393.71 / $3,370.39
| Professional | | $369.21 | $2,393.71 | $3,370.39 |