- 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
- $2,326.81 / $2,326.81 / $2,326.81
| Professional | | $2,326.81 | $2,326.81 | $2,326.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.21 / $2,847.80 / $3,417.36
| Professional | | $2,223.21 | $2,847.80 | $3,417.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.43 / $3,296.78 / $3,892.24
| Professional | | $3,012.43 | $3,296.78 | $3,892.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,506.06 / $2,733.89 / $3,189.54
| Professional | | $2,506.06 | $2,733.89 | $3,189.54 |
- 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
- $2,323.80 / $2,847.80 / $3,723.84
| Professional | | $2,323.80 | $2,847.80 | $3,723.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,058.59 / $3,894.18
| Professional | | $29.27 | $2,058.59 | $3,894.18 |