- 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
- $1,483.69 / $1,483.69 / $1,575.65
| Professional | | $1,483.69 | $1,483.69 | $1,575.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.17 / $2,048.33 / $2,457.98
| Professional | | $1,598.17 | $2,048.33 | $2,457.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.48 / $2,426.23 / $2,821.21
| Professional | | $2,159.48 | $2,426.23 | $2,821.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.53 / $1,966.39 / $2,294.12
| Professional | | $1,802.53 | $1,966.39 | $2,294.12 |
- 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
- $1,665.53 / $2,048.33 / $2,655.84
| Professional | | $1,665.53 | $2,048.33 | $2,655.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,506.09 / $2,524.19
| Professional | | $29.27 | $1,506.09 | $2,524.19 |