- 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
- $1,186.61 / $1,525.27 / $1,730.19
| Professional | | $1,186.61 | $1,525.27 | $1,730.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.76 / $1,389.88 / $1,667.85
| Professional | | $1,076.76 | $1,389.88 | $1,667.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.06 / $1,752.77 / $5,851.00
| Professional | | $1,560.06 | $1,752.77 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.08 / $1,334.28 / $1,556.66
| Professional | | $1,223.08 | $1,334.28 | $1,556.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.14 / $1,389.88 / $1,788.81
| Professional | | $1,134.14 | $1,389.88 | $1,788.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.00 / $2,575.00 / $6,124.00
| Professional | | $1,005.00 | $2,575.00 | $6,124.00 |