- 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
- $1,001.46 / $1,100.88 / $1,100.88
| Professional | | $1,001.46 | $1,100.88 | $1,100.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.02 / $1,462.15 / $1,462.15
| Professional | | $1,178.02 | $1,462.15 | $1,462.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.11 / $1,758.44 / $2,074.96
| Professional | | $1,565.11 | $1,758.44 | $2,074.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.69 / $1,403.66 / $1,637.61
| Professional | | $1,286.69 | $1,403.66 | $1,637.61 |
- 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
- $1,193.10 / $1,462.15 / $1,867.89
| Professional | | $1,193.10 | $1,462.15 | $1,867.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.00 / $3,692.19 / $9,324.00
| Professional | | $1,415.00 | $3,692.19 | $9,324.00 |