- 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
- $795.36 / $960.28 / $960.28
| Professional | | $795.36 | $960.28 | $960.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.62 / $1,598.08 / $1,598.08
| Professional | | $1,018.62 | $1,598.08 | $1,598.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.65 / $2,034.09 / $4,116.00
| Professional | | $1,735.65 | $2,034.09 | $4,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.31 / $1,534.15 / $1,789.84
| Professional | | $1,406.31 | $1,534.15 | $1,789.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.03 / $1,543.72 / $1,993.85
| Professional | | $1,304.03 | $1,543.72 | $1,993.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.33 / $3,900.00 / $8,000.00
| Professional | | $1,272.33 | $3,900.00 | $8,000.00 |