- 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
- $966.86 / $966.86 / $1,484.92
| Professional | | $966.86 | $966.86 | $1,484.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.97 / $1,173.99 / $1,408.79
| Professional | | $957.97 | $1,173.99 | $1,408.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.68 / $1,360.80 / $2,518.19
| Professional | | $1,239.68 | $1,360.80 | $2,518.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.10 / $1,127.03 / $1,314.87
| Professional | | $1,033.10 | $1,127.03 | $1,314.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.97 / $1,173.99 / $2,420.23
| Professional | | $957.97 | $1,173.99 | $2,420.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.00 / $2,650.00 / $6,124.00
| Professional | | $1,005.00 | $2,650.00 | $6,124.00 |