- 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
- $1,032.75 / $1,032.75 / $1,032.75
| Professional | | $1,032.75 | $1,032.75 | $1,032.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.53 / $1,253.96 / $1,504.76
| Professional | | $978.53 | $1,253.96 | $1,504.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.43 / $1,498.15 / $5,851.00
| Professional | | $1,333.43 | $1,498.15 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.49 / $1,203.80 / $1,404.44
| Professional | | $1,103.49 | $1,203.80 | $1,404.44 |
- 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
- $1,021.46 / $1,253.96 / $1,621.83
| Professional | | $1,021.46 | $1,253.96 | $1,621.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.18 / $2,000.00 / $5,304.00
| Professional | | $906.18 | $2,000.00 | $5,304.00 |