- 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
- $1,281.24 / $1,281.24 / $1,281.24
| Professional | | $1,281.24 | $1,281.24 | $1,281.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.04 / $1,809.03 / $2,170.83
| Professional | | $1,422.04 | $1,809.03 | $2,170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.14 / $2,115.61 / $2,497.73
| Professional | | $1,933.14 | $2,115.61 | $2,497.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.94 / $1,736.66 / $2,026.11
| Professional | | $1,591.94 | $1,736.66 | $2,026.11 |
- 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
- $1,427.67 / $1,809.03 / $2,285.60
| Professional | | $1,427.67 | $1,809.03 | $2,285.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.40 / $3,619.79 / $9,324.00
| Professional | | $1,388.40 | $3,619.79 | $9,324.00 |