- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $4,456.00 / $5,299.00
| Facility | | $1,758.00 | $4,456.00 | $5,299.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.16 / $982.17 / $982.17
| Professional | | $982.16 | $982.17 | $982.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.89 / $1,215.89 / $1,215.89
| Professional | | $1,215.89 | $1,215.89 | $1,215.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.57 / $1,451.94 / $1,789.35
| Professional | | $1,322.57 | $1,451.94 | $1,789.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.20 / $1,578.00 / $1,685.31
| Professional | | $1,016.20 | $1,578.00 | $1,685.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,284.48 / $1,797.68
| Professional | | $29.27 | $1,284.48 | $1,797.68 |