- 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
- $1,225.67 / $1,320.07 / $1,835.64
| Professional | | $1,225.67 | $1,320.07 | $1,835.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.82 / $1,440.76 / $1,728.92
| Professional | | $1,244.82 | $1,440.76 | $1,728.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.95 / $1,895.34 / $13,672.00
| Professional | | $1,686.95 | $1,895.34 | $13,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.86 / $1,383.13 / $1,613.65
| Professional | | $1,267.86 | $1,383.13 | $1,613.65 |
- 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
- $1,081.26 / $1,440.76 / $1,859.57
| Professional | | $1,081.26 | $1,440.76 | $1,859.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.33 / $6,954.00 / $9,691.00
| Professional | | $1,292.33 | $6,954.00 | $9,691.00 |