- 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
- $1,866.26 / $1,866.26 / $1,866.26
| Professional | | $1,866.26 | $1,866.26 | $1,866.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.90 / $2,204.96 / $2,645.96
| Professional | | $1,728.90 | $2,204.96 | $2,645.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.31 / $2,582.01 / $3,048.37
| Professional | | $2,359.31 | $2,582.01 | $3,048.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.37 / $2,116.76 / $2,469.56
| Professional | | $1,940.37 | $2,116.76 | $2,469.56 |
- 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
- $1,799.25 / $2,204.96 / $2,885.49
| Professional | | $1,799.25 | $2,204.96 | $2,885.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,912.87 / $2,424.46
| Professional | | $29.27 | $1,912.87 | $2,424.46 |