- 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
- $1,506.43 / $1,506.43 / $1,506.43
| Professional | | $1,506.43 | $1,506.43 | $1,506.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.05 / $1,722.28 / $2,066.73
| Professional | | $1,488.05 | $1,722.28 | $2,066.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.70 / $2,022.11 / $2,449.62
| Professional | | $1,847.70 | $2,022.11 | $2,449.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.60 / $1,653.38 / $1,928.95
| Professional | | $1,515.60 | $1,653.38 | $1,928.95 |
- 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
- $1,194.24 / $1,668.54 / $2,098.40
| Professional | | $1,194.24 | $1,668.54 | $2,098.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.78 / $3,692.19 / $9,324.00
| Professional | | $1,263.78 | $3,692.19 | $9,324.00 |