- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $6,084.00 / $7,424.00
| Facility | | $2,528.00 | $6,084.00 | $7,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.83 / $1,308.82 / $1,308.82
| Professional | | $1,126.83 | $1,308.82 | $1,308.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.65 / $1,958.21 / $1,958.21
| Professional | | $1,419.65 | $1,958.21 | $1,958.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.44 / $2,330.71 / $2,750.24
| Professional | | $2,074.44 | $2,330.71 | $2,750.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.23 / $1,879.88 / $2,193.19
| Professional | | $1,723.23 | $1,879.88 | $2,193.19 |
- 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
- $1,840.59 / $1,978.29 / $2,459.33
| Professional | | $1,840.59 | $1,978.29 | $2,459.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.83 / $1,901.26 / $2,134.75
| Professional | | $266.83 | $1,901.26 | $2,134.75 |