- 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
- $1,044.24 / $1,242.64 / $1,326.55
| Professional | | $1,044.24 | $1,242.64 | $1,326.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.97 / $1,636.15 / $1,939.85
| Professional | | $1,318.97 | $1,636.15 | $1,939.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.93 / $2,105.46 / $2,335.73
| Professional | | $1,829.93 | $2,105.46 | $2,335.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.05 / $1,707.07 / $2,172.63
| Professional | | $1,308.05 | $1,707.07 | $2,172.63 |
- 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
- $1,582.92 / $1,939.85 / $2,453.64
| Professional | | $1,582.92 | $1,939.85 | $2,453.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.11 / $3,520.00 / $9,057.00
| Professional | | $1,312.11 | $3,520.00 | $9,057.00 |