- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $6,084.00 / $7,424.00
| Facility | | $2,528.00 | $6,084.00 | $7,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.39 / $1,763.94 / $1,763.94
| Professional | | $1,604.39 | $1,763.94 | $1,763.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.13 / $2,339.33 / $2,339.33
| Professional | | $1,891.13 | $2,339.33 | $2,339.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.08 / $2,810.04 / $3,315.85
| Professional | | $2,501.08 | $2,810.04 | $3,315.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.61 / $2,245.75 / $2,620.04
| Professional | | $2,058.61 | $2,245.75 | $2,620.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.89 / $2,339.33 / $2,997.02
| Professional | | $1,908.89 | $2,339.33 | $2,997.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,292.27 / $3,119.92
| Professional | | $29.27 | $2,292.27 | $3,119.92 |