- 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
- $1,166.59 / $1,272.39 / $1,480.71
| Professional | | $1,166.59 | $1,272.39 | $1,480.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.19 / $1,718.32 / $1,886.28
| Professional | | $1,466.19 | $1,718.32 | $1,886.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.81 / $2,168.62 / $2,405.76
| Professional | | $1,884.81 | $2,168.62 | $2,405.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.00 / $1,692.73 / $2,112.63
| Professional | | $1,330.00 | $1,692.73 | $2,112.63 |
- 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
- $1,539.20 / $1,886.28 / $2,391.96
| Professional | | $1,539.20 | $1,886.28 | $2,391.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.05 / $3,520.00 / $9,057.00
| Professional | | $1,375.05 | $3,520.00 | $9,057.00 |