- 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
- $1,322.53 / $1,534.32 / $1,534.32
| Professional | | $1,322.53 | $1,534.32 | $1,534.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.95 / $2,137.05 / $2,137.05
| Professional | | $1,661.95 | $2,137.05 | $2,137.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.42 / $2,662.12 / $3,141.30
| Professional | | $2,369.42 | $2,662.12 | $3,141.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.60 / $2,051.57 / $2,393.50
| Professional | | $1,880.60 | $2,051.57 | $2,393.50 |
- 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
- $1,743.83 / $2,137.05 / $2,718.75
| Professional | | $1,743.83 | $2,137.05 | $2,718.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.95 / $2,094.48 / $2,351.69
| Professional | | $293.95 | $2,094.48 | $2,351.69 |