- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.13 / $3,107.00 / $8,431.00
| Facility | | $2,583.13 | $3,107.00 | $8,431.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.15 / $1,418.66 / $1,418.66
| Professional | | $1,163.15 | $1,418.66 | $1,418.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.59 / $2,237.33 / $2,237.33
| Professional | | $1,498.59 | $2,237.33 | $2,237.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,418.36 / $2,834.19 / $8,507.00
| Professional | | $2,418.36 | $2,834.19 | $8,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.85 / $2,147.83 / $2,505.80
| Professional | | $1,968.85 | $2,147.83 | $2,505.80 |
- 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
- $1,825.66 / $2,237.33 / $2,844.47
| Professional | | $1,825.66 | $2,237.33 | $2,844.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.32 / $5,316.74 / $11,157.30
| Professional | | $1,860.32 | $5,316.74 | $11,157.30 |