- 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
- $2,296.08 / $2,296.08 / $2,296.08
| Professional | | $2,296.08 | $2,296.08 | $2,296.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.23 / $2,640.45 / $3,168.54
| Professional | | $2,055.23 | $2,640.45 | $3,168.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.05 / $3,200.06 / $3,778.05
| Professional | | $2,924.05 | $3,200.06 | $3,778.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.60 / $2,534.83 / $2,957.30
| Professional | | $2,323.60 | $2,534.83 | $2,957.30 |
- 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
- $2,154.61 / $2,640.45 / $3,439.73
| Professional | | $2,154.61 | $2,640.45 | $3,439.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,270.44 / $2,872.08
| Professional | | $29.27 | $2,270.44 | $2,872.08 |