- 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
- $1,651.80 / $1,651.80 / $1,651.80
| Professional | | $1,651.80 | $1,651.80 | $1,651.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.62 / $2,003.73 / $2,404.46
| Professional | | $1,569.62 | $2,003.73 | $2,404.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.34 / $2,385.64 / $2,774.00
| Professional | | $2,123.34 | $2,385.64 | $2,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.28 / $1,923.58 / $2,244.17
| Professional | | $1,763.28 | $1,923.58 | $2,244.17 |
- 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
- $1,635.04 / $2,003.73 / $2,652.93
| Professional | | $1,635.04 | $2,003.73 | $2,652.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,451.02 / $2,811.01
| Professional | | $29.27 | $1,451.02 | $2,811.01 |