- 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
- $1,682.66 / $1,682.66 / $1,682.66
| Professional | | $1,682.66 | $1,682.66 | $1,682.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.00 / $2,035.58 / $2,442.69
| Professional | | $1,582.00 | $2,035.58 | $2,442.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.69 / $2,349.33 / $2,773.66
| Professional | | $2,146.69 | $2,349.33 | $2,773.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.31 / $1,954.15 / $2,279.84
| Professional | | $1,791.31 | $1,954.15 | $2,279.84 |
- 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
- $1,660.48 / $2,035.58 / $2,628.83
| Professional | | $1,660.48 | $2,035.58 | $2,628.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,706.05 / $2,204.75
| Professional | | $29.27 | $1,706.05 | $2,204.75 |