- 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
- $1,311.50 / $1,442.19 / $1,442.19
| Professional | | $1,311.50 | $1,442.19 | $1,442.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.20 / $1,876.59 / $1,876.59
| Professional | | $1,546.20 | $1,876.59 | $1,876.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.28 / $2,254.12 / $2,659.86
| Professional | | $2,006.28 | $2,254.12 | $2,659.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.40 / $1,801.52 / $2,101.78
| Professional | | $1,651.40 | $1,801.52 | $2,101.78 |
- 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
- $1,531.30 / $1,876.59 / $2,423.84
| Professional | | $1,531.30 | $1,876.59 | $2,423.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.79 / $5,316.74 / $11,157.30
| Professional | | $1,838.79 | $5,316.74 | $11,157.30 |