- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $5,484.00 / $6,718.00
| Facility | | $1,924.00 | $5,484.00 | $6,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.41 / $2,010.22 / $2,010.22
| Professional | | $1,823.41 | $2,010.22 | $2,010.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.58 / $2,652.60 / $2,652.60
| Professional | | $2,151.58 | $2,652.60 | $2,652.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,834.69 / $3,184.86 / $3,758.13
| Professional | | $2,834.69 | $3,184.86 | $3,758.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.29 / $2,546.50 / $2,970.91
| Professional | | $2,334.29 | $2,546.50 | $2,970.91 |
- 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
- $2,164.52 / $2,652.60 / $3,406.40
| Professional | | $2,164.52 | $2,652.60 | $3,406.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,598.03 / $3,629.92
| Professional | | $29.27 | $2,598.03 | $3,629.92 |