- 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
- $2,899.31 / $2,899.31 / $2,899.31
| Professional | | $2,899.31 | $2,899.31 | $2,899.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.76 / $3,193.84 / $3,832.61
| Professional | | $2,510.76 | $3,193.84 | $3,832.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,394.34 / $3,813.64 / $4,434.46
| Professional | | $3,394.34 | $3,813.64 | $4,434.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,810.58 / $3,066.08 / $3,577.10
| Professional | | $2,810.58 | $3,066.08 | $3,577.10 |
- 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
- $2,606.17 / $3,193.84 / $4,137.35
| Professional | | $2,606.17 | $3,193.84 | $4,137.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,319.57 / $5,099.05
| Professional | | $29.27 | $2,319.57 | $5,099.05 |