- 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
- $2,648.71 / $2,648.71 / $2,648.71
| Professional | | $2,648.71 | $2,648.71 | $2,648.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.90 / $3,040.60 / $3,648.72
| Professional | | $2,367.90 | $3,040.60 | $3,648.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,387.06 / $3,706.77 / $4,376.29
| Professional | | $3,387.06 | $3,706.77 | $4,376.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.73 / $2,918.98 / $3,405.47
| Professional | | $2,675.73 | $2,918.98 | $3,405.47 |
- 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
- $2,481.13 / $3,040.60 / $3,958.31
| Professional | | $2,481.13 | $3,040.60 | $3,958.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,510.11 / $3,307.32
| Professional | | $29.27 | $2,510.11 | $3,307.32 |