- 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
- $873.69 / $961.76 / $961.76
| Professional | | $873.69 | $961.76 | $961.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.01 / $1,248.44 / $1,248.44
| Professional | | $1,027.01 | $1,248.44 | $1,248.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.80 / $1,538.11 / $8,902.00
| Professional | | $1,336.80 | $1,538.11 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.63 / $1,198.50 / $1,398.25
| Professional | | $1,098.63 | $1,198.50 | $1,398.25 |
- 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
- $1,018.73 / $1,248.44 / $1,607.79
| Professional | | $1,018.73 | $1,248.44 | $1,607.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.19 / $5,316.74 / $11,157.30
| Professional | | $1,225.19 | $5,316.74 | $11,157.30 |