- 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
- $1,717.77 / $1,717.77 / $1,717.77
| Professional | | $1,717.77 | $1,717.77 | $1,717.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.81 / $2,112.10 / $2,534.52
| Professional | | $1,648.81 | $2,112.10 | $2,534.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.77 / $2,509.71 / $2,918.26
| Professional | | $2,233.77 | $2,509.71 | $2,918.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.65 / $2,027.62 / $2,365.55
| Professional | | $1,858.65 | $2,027.62 | $2,365.55 |
- 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
- $1,723.47 / $2,112.10 / $2,748.92
| Professional | | $1,723.47 | $2,112.10 | $2,748.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,526.47 / $2,828.36
| Professional | | $29.27 | $1,526.47 | $2,828.36 |