- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.29 / $851.48 / $851.48
| Professional | | $716.29 | $851.48 | $851.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.65 / $1,227.58 / $1,227.58
| Professional | | $912.65 | $1,227.58 | $1,227.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.57 / $1,454.48 / $1,716.29
| Professional | | $1,294.57 | $1,454.48 | $1,716.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.27 / $1,178.47 / $1,374.88
| Professional | | $1,080.27 | $1,178.47 | $1,374.88 |
- 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
- $1,001.70 / $1,227.58 / $1,457.54
| Professional | | $1,001.70 | $1,227.58 | $1,457.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.21 / $3,692.19 / $9,324.00
| Professional | | $1,139.21 | $3,692.19 | $9,324.00 |