- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.55 / $2,747.00 / $5,484.00
| Facility | | $1,635.55 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.49 / $1,242.49 / $1,242.49
| Professional | | $1,242.49 | $1,242.49 | $1,242.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.11 / $1,640.94 / $1,969.13
| Professional | | $1,277.11 | $1,640.94 | $1,969.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.57 / $1,942.10 / $5,851.00
| Professional | | $1,728.57 | $1,942.10 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.03 / $1,575.30 / $1,837.85
| Professional | | $1,444.03 | $1,575.30 | $1,837.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.76 / $1,460.36 / $2,073.06
| Professional | | $1,297.76 | $1,460.36 | $2,073.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.51 / $3,191.04 / $8,000.00
| Professional | | $1,311.51 | $3,191.04 | $8,000.00 |