- 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
- $970.10 / $1,188.84 / $1,426.62
| Professional | | $970.10 | $1,188.84 | $1,426.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.93 / $1,361.35 / $1,649.17
| Professional | | $1,243.93 | $1,361.35 | $1,649.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.19 / $1,141.30 / $1,331.51
| Professional | | $1,046.19 | $1,141.30 | $1,331.51 |
- 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
- $970.10 / $1,188.84 / $2,385.38
| Professional | | $970.10 | $1,188.84 | $2,385.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.06 / $2,650.00 / $6,124.00
| Professional | | $850.06 | $2,650.00 | $6,124.00 |