- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.80 / $1,404.80 / $1,404.80
| Professional | | $1,404.80 | $1,404.80 | $1,404.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.25 / $1,953.84 / $2,344.61
| Professional | | $1,531.25 | $1,953.84 | $2,344.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.17 / $2,275.42 / $2,686.42
| Professional | | $2,079.17 | $2,275.42 | $2,686.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.38 / $1,875.68 / $2,188.30
| Professional | | $1,719.38 | $1,875.68 | $2,188.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.62 / $1,953.84 / $2,457.92
| Professional | | $1,533.62 | $1,953.84 | $2,457.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.00 / $3,619.79 / $9,324.00
| Professional | | $1,415.00 | $3,619.79 | $9,324.00 |