- 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
- $1,078.03 / $1,182.28 / $1,182.28
| Professional | | $1,078.03 | $1,182.28 | $1,182.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.91 / $1,624.16 / $1,624.16
| Professional | | $1,258.91 | $1,624.16 | $1,624.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.20 / $2,008.01 / $8,902.00
| Professional | | $1,745.20 | $2,008.01 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.26 / $1,559.20 / $1,819.06
| Professional | | $1,429.26 | $1,559.20 | $1,819.06 |
- 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
- $1,325.32 / $1,624.16 / $2,018.03
| Professional | | $1,325.32 | $1,624.16 | $2,018.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.29 / $5,316.74 / $11,157.30
| Professional | | $1,556.29 | $5,316.74 | $11,157.30 |