- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $2,747.00 / $6,084.00
| Facility | | $2,528.00 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.75 / $1,886.41 / $3,152.58
| Professional | | $1,652.75 | $1,886.41 | $3,152.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.95 / $2,543.88 / $3,052.65
| Professional | | $2,001.95 | $2,543.88 | $3,052.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,725.62 / $3,062.31 / $3,560.83
| Professional | | $2,725.62 | $3,062.31 | $3,560.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.61 / $2,442.12 / $2,849.14
| Professional | | $2,238.61 | $2,442.12 | $2,849.14 |
- 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
- $2,048.84 / $2,543.88 / $3,239.18
| Professional | | $2,048.84 | $2,543.88 | $3,239.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,862.59 / $2,882.68
| Professional | | $29.27 | $1,862.59 | $2,882.68 |