- 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
- $1,145.42 / $1,329.66 / $1,329.66
| Professional | | $1,145.42 | $1,329.66 | $1,329.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.27 / $1,893.23 / $1,893.23
| Professional | | $1,441.27 | $1,893.23 | $1,893.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.67 / $2,302.87 / $2,717.39
| Professional | | $2,049.67 | $2,302.87 | $2,717.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.04 / $1,817.50 / $2,120.41
| Professional | | $1,666.04 | $1,817.50 | $2,120.41 |
- 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
- $1,544.87 / $1,893.23 / $2,374.94
| Professional | | $1,544.87 | $1,893.23 | $2,374.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.08 / $1,838.83 / $2,064.65
| Professional | | $258.08 | $1,838.83 | $2,064.65 |