- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.37 / $1,552.37 / $1,552.37
| Professional | | $1,552.37 | $1,552.37 | $1,552.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.46 / $1,774.84 / $2,129.81
| Professional | | $1,533.46 | $1,774.84 | $2,129.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.92 / $2,084.71 / $2,525.46
| Professional | | $1,904.92 | $2,084.71 | $2,525.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.86 / $1,703.84 / $1,987.82
| Professional | | $1,561.86 | $1,703.84 | $1,987.82 |
- 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
- $1,232.83 / $1,720.14 / $2,166.14
| Professional | | $1,232.83 | $1,720.14 | $2,166.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.75 / $3,692.19 / $9,324.00
| Professional | | $1,301.75 | $3,692.19 | $9,324.00 |