- 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
- $1,101.02 / $1,210.67 / $1,210.67
| Professional | | $1,101.02 | $1,210.67 | $1,210.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.32 / $1,657.35 / $1,657.35
| Professional | | $1,286.32 | $1,657.35 | $1,657.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.29 / $2,000.21 / $2,360.25
| Professional | | $1,780.29 | $2,000.21 | $2,360.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.47 / $1,591.06 / $1,856.23
| Professional | | $1,458.47 | $1,591.06 | $1,856.23 |
- 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
- $1,352.40 / $1,657.35 / $2,060.36
| Professional | | $1,352.40 | $1,657.35 | $2,060.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.94 / $5,316.74 / $11,157.30
| Professional | | $1,590.94 | $5,316.74 | $11,157.30 |