- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,456.00
| Facility | | $1,324.03 | $2,747.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.37 / $933.50 / $1,458.33
| Professional | | $778.37 | $933.50 | $1,458.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.52 / $1,136.66 / $1,364.00
| Professional | | $927.52 | $1,136.66 | $1,364.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.65 / $1,319.61 / $3,935.00
| Professional | | $1,143.65 | $1,319.61 | $3,935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.01 / $1,000.26 / $1,136.66
| Professional | | $822.01 | $1,000.26 | $1,136.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.52 / $1,136.66 / $2,264.90
| Professional | | $927.52 | $1,136.66 | $2,264.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.35 / $2,575.00 / $6,124.00
| Professional | | $756.35 | $2,575.00 | $6,124.00 |