- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $2,747.00 / $5,484.00
| Facility | | $1,924.00 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,920.35 / $2,920.35 / $2,920.35
| Professional | | $2,920.35 | $2,920.35 | $2,920.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,726.35 / $3,504.85 / $4,205.82
| Professional | | $2,726.35 | $3,504.85 | $4,205.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,820.21 / $4,180.80 / $4,935.93
| Professional | | $3,820.21 | $4,180.80 | $4,935.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,084.27 / $3,364.66 / $3,925.43
| Professional | | $3,084.27 | $3,364.66 | $3,925.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.96 / $3,504.85 / $4,546.60
| Professional | | $2,859.96 | $3,504.85 | $4,546.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,003.81 / $4,804.75
| Professional | | $29.27 | $3,003.81 | $4,804.75 |