- 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
- $2,173.85 / $2,173.85 / $2,173.85
| Professional | | $2,173.85 | $2,173.85 | $2,173.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.91 / $2,712.63 / $3,255.15
| Professional | | $2,117.91 | $2,712.63 | $3,255.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,875.18 / $3,146.59 / $3,714.91
| Professional | | $2,875.18 | $3,146.59 | $3,714.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.11 / $2,604.12 / $3,038.14
| Professional | | $2,387.11 | $2,604.12 | $3,038.14 |
- 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
- $1,790.72 / $2,712.63 / $3,480.54
| Professional | | $1,790.72 | $2,712.63 | $3,480.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.84 / $2,416.44 / $2,958.76
| Professional | | $369.84 | $2,416.44 | $2,958.76 |