- 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
- $897.14 / $1,079.55 / $1,079.55
| Professional | | $897.14 | $1,079.55 | $1,079.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.34 / $1,541.98 / $1,541.98
| Professional | | $1,155.34 | $1,541.98 | $1,541.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.71 / $1,865.86 / $2,201.71
| Professional | | $1,660.71 | $1,865.86 | $2,201.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.94 / $1,480.30 / $1,727.01
| Professional | | $1,356.94 | $1,480.30 | $1,727.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.25 / $1,541.98 / $1,910.15
| Professional | | $1,258.25 | $1,541.98 | $1,910.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.00 / $3,900.00 / $8,000.00
| Professional | | $1,364.00 | $3,900.00 | $8,000.00 |