- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $8,431.00 / $10,303.00
| Facility | | $2,747.00 | $8,431.00 | $10,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.40 / $1,424.29 / $1,424.29
| Professional | | $1,085.40 | $1,424.29 | $1,424.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.19 / $2,017.95 / $2,017.95
| Professional | | $1,407.19 | $2,017.95 | $2,017.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.44 / $2,491.54 / $8,902.00
| Professional | | $2,165.44 | $2,491.54 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.80 / $1,937.23 / $2,260.10
| Professional | | $1,775.80 | $1,937.23 | $2,260.10 |
- 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
- $1,646.65 / $2,017.95 / $2,596.58
| Professional | | $1,646.65 | $2,017.95 | $2,596.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.79 / $9,435.00 / $12,953.00
| Professional | | $1,479.79 | $9,435.00 | $12,953.00 |