- 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
- $1,955.48 / $1,955.48 / $1,955.48
| Professional | | $1,955.48 | $1,955.48 | $1,955.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.28 / $2,042.69 / $2,451.23
| Professional | | $1,602.28 | $2,042.69 | $2,451.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.23 / $2,560.03 / $3,022.42
| Professional | | $2,339.23 | $2,560.03 | $3,022.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.57 / $1,960.98 / $2,287.81
| Professional | | $1,797.57 | $1,960.98 | $2,287.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.83 / $2,042.69 / $2,794.97
| Professional | | $1,666.83 | $2,042.69 | $2,794.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,502.58 / $2,245.03
| Professional | | $29.27 | $1,502.58 | $2,245.03 |