- 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
- $1,396.05 / $1,396.05 / $1,396.05
| Professional | | $1,396.05 | $1,396.05 | $1,396.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.19 / $1,758.38 / $2,110.05
| Professional | | $1,387.19 | $1,758.38 | $2,110.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.66 / $2,066.92 / $2,440.25
| Professional | | $1,888.66 | $2,066.92 | $2,440.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.37 / $1,688.04 / $1,969.38
| Professional | | $1,547.37 | $1,688.04 | $1,969.38 |
- 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
- $1,422.34 / $1,758.38 / $2,233.94
| Professional | | $1,422.34 | $1,758.38 | $2,233.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.00 / $2,575.00 / $6,124.00
| Professional | | $1,161.00 | $2,575.00 | $6,124.00 |