- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,317.30 / $13,317.30 / $13,317.30
| Facility | | $13,317.30 | $13,317.30 | $13,317.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.95 / $4,348.67 / $6,220.96
| Professional | | $1,733.95 | $4,348.67 | $6,220.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,316.69 / $2,316.69 / $2,316.69
| Professional | | $2,316.69 | $2,316.69 | $2,316.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,457.52 / $4,104.30 / $4,540.14
| Professional | | $3,457.52 | $4,104.30 | $4,540.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.77 / $2,767.88 / $3,229.20
| Professional | | $2,375.77 | $2,767.88 | $3,229.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.64 / $3,338.15 / $3,438.65
| Professional | | $2,171.64 | $3,338.15 | $3,438.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.55 / $2,300.53 / $2,706.50
| Professional | | $1,894.55 | $2,300.53 | $2,706.50 |