- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $6,966.00 / $8,499.00
| Facility | | $2,747.00 | $6,966.00 | $8,499.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.21 / $1,579.21 / $1,579.21
| Professional | | $1,579.21 | $1,579.21 | $1,579.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.32 / $1,378.33 / $1,849.49
| Professional | | $976.32 | $1,378.33 | $1,849.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.18 / $1,643.93 / $10,286.10
| Professional | | $1,463.18 | $1,643.93 | $10,286.10 |
- 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
- $976.32 / $2,090.94 / $2,549.31
| Professional | | $976.32 | $2,090.94 | $2,549.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.09 / $1,525.38 / $1,712.70
| Professional | | $214.09 | $1,525.38 | $1,712.70 |