- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $5,484.00 / $6,718.00
| Facility | | $1,924.00 | $5,484.00 | $6,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.60 / $3,350.00 / $4,020.00
| Professional | | $2,733.60 | $3,350.00 | $4,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,534.40 / $3,868.02 / $4,685.79
| Professional | | $3,534.40 | $3,868.02 | $4,685.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,948.00 / $3,216.00 / $3,752.00
| Professional | | $2,948.00 | $3,216.00 | $3,752.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.71 / $3,316.76 / $4,362.53
| Professional | | $2,044.71 | $3,316.76 | $4,362.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,415.28 / $3,381.40
| Professional | | $29.27 | $2,415.28 | $3,381.40 |