- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.55 / $2,747.00 / $5,484.00
| Facility | | $1,635.55 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.10 / $2,228.06 / $2,673.68
| Professional | | $1,818.10 | $2,228.06 | $2,673.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.78 / $2,562.83 / $3,104.65
| Professional | | $2,341.78 | $2,562.83 | $3,104.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.70 / $2,138.94 / $2,495.42
| Professional | | $1,960.70 | $2,138.94 | $2,495.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.10 / $2,228.06 / $4,727.70
| Professional | | $1,818.10 | $2,228.06 | $4,727.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.05 / $4,057.27 / $8,007.00
| Professional | | $1,368.05 | $4,057.27 | $8,007.00 |