- 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
- $1,889.29 / $1,889.29 / $1,889.29
| Professional | | $1,889.29 | $1,889.29 | $1,889.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.31 / $2,370.73 / $2,844.89
| Professional | | $1,848.31 | $2,370.73 | $2,844.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,506.53 / $2,816.16 / $3,274.60
| Professional | | $2,506.53 | $2,816.16 | $3,274.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.25 / $2,275.91 / $2,655.23
| Professional | | $2,086.25 | $2,275.91 | $2,655.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.76 / $2,370.73 / $3,025.59
| Professional | | $1,917.76 | $2,370.73 | $3,025.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,900.74 / $2,579.38
| Professional | | $29.27 | $1,900.74 | $2,579.38 |