- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.15 / $1,033.15 / $1,033.15
| Professional | | $1,033.15 | $1,033.15 | $1,033.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.12 / $1,271.84 / $1,526.22
| Professional | | $985.12 | $1,271.84 | $1,526.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.51 / $1,457.19 / $1,720.39
| Professional | | $1,331.51 | $1,457.19 | $1,720.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.23 / $1,220.98 / $1,424.47
| Professional | | $1,119.23 | $1,220.98 | $1,424.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.50 / $1,271.84 / $1,617.09
| Professional | | $1,030.50 | $1,271.84 | $1,617.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.53 / $3,619.79 / $9,324.00
| Professional | | $1,086.53 | $3,619.79 | $9,324.00 |