- 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
- $986.87 / $1,131.43 / $1,131.43
| Professional | | $986.87 | $1,131.43 | $1,131.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.48 / $1,733.65 / $1,733.65
| Professional | | $1,264.48 | $1,733.65 | $1,733.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.01 / $2,204.44 / $5,879.00
| Professional | | $1,881.01 | $2,204.44 | $5,879.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.61 / $1,664.30 / $1,941.69
| Professional | | $1,525.61 | $1,664.30 | $1,941.69 |
- 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
- $1,414.66 / $1,733.65 / $2,174.96
| Professional | | $1,414.66 | $1,733.65 | $2,174.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.41 / $3,692.19 / $9,324.00
| Professional | | $1,411.41 | $3,692.19 | $9,324.00 |