- 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
- $2,062.78 / $2,062.78 / $2,062.78
| Professional | | $2,062.78 | $2,062.78 | $2,062.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,045.73 / $2,621.60 / $3,145.92
| Professional | | $2,045.73 | $2,621.60 | $3,145.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,771.38 / $3,113.73 / $3,857.00
| Professional | | $2,771.38 | $3,113.73 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.01 / $2,516.73 / $2,936.19
| Professional | | $2,307.01 | $2,516.73 | $2,936.19 |
- 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
- $2,139.23 / $2,621.60 / $3,421.97
| Professional | | $2,139.23 | $2,621.60 | $3,421.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,893.86 / $3,494.72
| Professional | | $29.27 | $1,893.86 | $3,494.72 |