- 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
- $1,217.34 / $1,217.34 / $1,220.81
| Professional | | $1,217.34 | $1,217.34 | $1,220.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.83 / $1,482.38 / $1,482.38
| Professional | | $1,189.83 | $1,482.38 | $1,482.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.52 / $1,828.88 / $11,782.00
| Professional | | $1,589.52 | $1,828.88 | $11,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.49 / $1,423.08 / $1,660.26
| Professional | | $1,304.49 | $1,423.08 | $1,660.26 |
- 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
- $1,209.61 / $1,482.38 / $1,942.04
| Professional | | $1,209.61 | $1,482.38 | $1,942.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.46 / $1,456.81 / $2,059.50
| Professional | | $204.46 | $1,456.81 | $2,059.50 |