- 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
- $1,022.61 / $1,022.61 / $1,581.24
| Professional | | $1,022.61 | $1,022.61 | $1,581.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.04 / $1,266.90 / $1,520.28
| Professional | | $995.04 | $1,266.90 | $1,520.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.25 / $1,515.92 / $5,851.00
| Professional | | $1,349.25 | $1,515.92 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.86 / $1,216.22 / $1,418.93
| Professional | | $1,114.86 | $1,216.22 | $1,418.93 |
- 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
- $963.23 / $1,266.90 / $1,655.70
| Professional | | $963.23 | $1,266.90 | $1,655.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.52 / $2,575.00 / $6,124.00
| Professional | | $922.52 | $2,575.00 | $6,124.00 |