- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.67 / $1,133.89 / $1,133.89
| Professional | | $961.67 | $1,133.89 | $1,133.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.20 / $1,652.35 / $1,652.35
| Professional | | $1,235.20 | $1,652.35 | $1,652.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.95 / $1,985.23 / $2,342.57
| Professional | | $1,766.95 | $1,985.23 | $2,342.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.07 / $1,586.26 / $1,850.63
| Professional | | $1,454.07 | $1,586.26 | $1,850.63 |
- 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
- $1,348.32 / $1,652.35 / $2,083.53
| Professional | | $1,348.32 | $1,652.35 | $2,083.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.00 / $3,692.19 / $9,324.00
| Professional | | $1,415.00 | $3,692.19 | $9,324.00 |