- 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
- $1,250.52 / $1,451.45 / $1,563.54
| Professional | | $1,250.52 | $1,451.45 | $1,563.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.04 / $2,136.13 / $2,136.13
| Professional | | $1,573.04 | $2,136.13 | $2,136.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.81 / $2,565.92 / $3,027.79
| Professional | | $2,283.81 | $2,565.92 | $3,027.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,879.79 / $2,050.67 / $2,392.46
| Professional | | $1,879.79 | $2,050.67 | $2,392.46 |
- 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
- $1,743.08 / $2,136.13 / $2,718.14
| Professional | | $1,743.08 | $2,136.13 | $2,718.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.77 / $2,093.13 / $2,350.17
| Professional | | $293.77 | $2,093.13 | $2,350.17 |