- 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
- $961.08 / $1,058.51 / $1,058.51
| Professional | | $961.08 | $1,058.51 | $1,058.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.16 / $1,412.98 / $1,412.98
| Professional | | $1,127.16 | $1,412.98 | $1,412.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.55 / $1,747.23 / $4,334.00
| Professional | | $1,518.55 | $1,747.23 | $4,334.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.42 / $1,356.46 / $1,582.53
| Professional | | $1,243.42 | $1,356.46 | $1,582.53 |
- 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
- $1,152.99 / $1,412.98 / $1,796.54
| Professional | | $1,152.99 | $1,412.98 | $1,796.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.09 / $5,316.74 / $11,157.30
| Professional | | $1,388.09 | $5,316.74 | $11,157.30 |