- 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
- $1,032.79 / $1,032.79 / $1,032.79
| Professional | | $1,032.79 | $1,032.79 | $1,032.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.61 / $1,251.75 / $1,502.10
| Professional | | $968.61 | $1,251.75 | $1,502.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.25 / $1,469.86 / $8,430.00
| Professional | | $1,308.25 | $1,469.86 | $8,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.54 / $1,201.68 / $1,401.96
| Professional | | $1,101.54 | $1,201.68 | $1,401.96 |
- 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
- $1,021.43 / $1,251.75 / $1,588.73
| Professional | | $1,021.43 | $1,251.75 | $1,588.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.03 / $3,900.00 / $8,000.00
| Professional | | $1,199.03 | $3,900.00 | $8,000.00 |