- 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
- $885.69 / $885.69 / $914.41
| Professional | | $885.69 | $885.69 | $914.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.15 / $1,088.26 / $1,305.92
| Professional | | $843.15 | $1,088.26 | $1,305.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.46 / $1,245.92 / $1,470.95
| Professional | | $1,138.46 | $1,245.92 | $1,470.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.67 / $1,044.73 / $1,218.84
| Professional | | $957.67 | $1,044.73 | $1,218.84 |
- 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
- $888.02 / $1,088.26 / $1,383.33
| Professional | | $888.02 | $1,088.26 | $1,383.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.72 / $2,575.00 / $6,124.00
| Professional | | $927.72 | $2,575.00 | $6,124.00 |