- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.13 / $3,107.00 / $8,431.00
| Facility | | $2,583.13 | $3,107.00 | $8,431.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.11 / $1,773.11 / $1,773.11
| Professional | | $1,773.11 | $1,773.11 | $1,773.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.60 / $2,016.90 / $2,420.28
| Professional | | $1,742.60 | $2,016.90 | $2,420.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.46 / $2,343.59 / $2,839.07
| Professional | | $2,141.46 | $2,343.59 | $2,839.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.87 / $1,936.22 / $2,258.92
| Professional | | $1,774.87 | $1,936.22 | $2,258.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.74 / $1,957.30 / $2,051.25
| Professional | | $1,439.74 | $1,957.30 | $2,051.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.79 / $5,316.74 / $11,157.30
| Professional | | $1,475.79 | $5,316.74 | $11,157.30 |