- 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
- $1,151.19 / $1,151.19 / $1,737.92
| Professional | | $1,151.19 | $1,151.19 | $1,737.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.09 / $1,403.31 / $1,403.31
| Professional | | $1,124.09 | $1,403.31 | $1,403.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.35 / $1,740.09 / $11,782.00
| Professional | | $1,512.35 | $1,740.09 | $11,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.92 / $1,347.18 / $1,571.71
| Professional | | $1,234.92 | $1,347.18 | $1,571.71 |
- 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
- $1,145.09 / $1,403.31 / $1,834.67
| Professional | | $1,145.09 | $1,403.31 | $1,834.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.55 / $7,934.00 / $11,700.00
| Professional | | $1,027.55 | $7,934.00 | $11,700.00 |