- 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
- $1,028.58 / $1,028.58 / $1,028.58
| Professional | | $1,028.58 | $1,028.58 | $1,028.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.05 / $1,405.69 / $1,686.83
| Professional | | $1,089.05 | $1,405.69 | $1,686.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.18 / $1,610.04 / $1,900.85
| Professional | | $1,471.18 | $1,610.04 | $1,900.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.01 / $1,349.46 / $1,574.37
| Professional | | $1,237.01 | $1,349.46 | $1,574.37 |
- 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
- $1,102.89 / $1,405.69 / $1,754.21
| Professional | | $1,102.89 | $1,405.69 | $1,754.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,005.35 / $1,581.43
| Professional | | $29.27 | $1,005.35 | $1,581.43 |