- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.88 / $2,747.00 / $3,883.00
| Facility | | $1,157.88 | $2,747.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.83 / $1,628.34 / $1,628.34
| Professional | | $1,373.83 | $1,628.34 | $1,628.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.50 / $2,243.01 / $2,243.01
| Professional | | $1,756.50 | $2,243.01 | $2,243.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.40 / $2,701.41 / $3,187.66
| Professional | | $2,404.40 | $2,701.41 | $3,187.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.85 / $2,153.29 / $2,512.17
| Professional | | $1,973.85 | $2,153.29 | $2,512.17 |
- 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
- $1,830.30 / $2,243.01 / $2,850.87
| Professional | | $1,830.30 | $2,243.01 | $2,850.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.00 / $2,474.28 / $5,304.00
| Professional | | $1,015.00 | $2,474.28 | $5,304.00 |