- 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
- $966.48 / $966.48 / $1,491.89
| Professional | | $966.48 | $966.48 | $1,491.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.43 / $1,179.45 / $1,415.34
| Professional | | $962.43 | $1,179.45 | $1,415.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.92 / $1,346.01 / $1,630.58
| Professional | | $1,229.92 | $1,346.01 | $1,630.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.92 / $1,132.27 / $1,320.98
| Professional | | $1,037.92 | $1,132.27 | $1,320.98 |
- 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
- $962.43 / $1,179.45 / $2,459.82
| Professional | | $962.43 | $1,179.45 | $2,459.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.21 / $840.48 / $1,097.57
| Professional | | $158.21 | $840.48 | $1,097.57 |