- 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
- $1,334.72 / $1,467.03 / $2,593.05
| Professional | | $1,334.72 | $1,467.03 | $2,593.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.18 / $2,011.76 / $2,011.76
| Professional | | $1,559.18 | $2,011.76 | $2,011.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.73 / $2,489.56 / $6,874.20
| Professional | | $2,163.73 | $2,489.56 | $6,874.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.35 / $1,931.29 / $2,253.17
| Professional | | $1,770.35 | $1,931.29 | $2,253.17 |
- 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
- $1,641.60 / $2,011.76 / $2,500.14
| Professional | | $1,641.60 | $2,011.76 | $2,500.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.24 / $5,316.74 / $11,157.30
| Professional | | $1,928.24 | $5,316.74 | $11,157.30 |