- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $4,456.00 / $5,299.00
| Facility | | $1,758.00 | $4,456.00 | $5,299.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.39 / $1,227.72 / $1,506.43
| Professional | | $1,114.39 | $1,227.72 | $1,506.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.01 / $1,543.40 / $3,170.29
| Professional | | $1,267.01 | $1,543.40 | $3,170.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.93 / $1,861.61 / $2,241.73
| Professional | | $1,656.93 | $1,861.61 | $2,241.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.80 / $1,481.66 / $1,728.61
| Professional | | $1,308.80 | $1,481.66 | $1,728.61 |
- 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
- $1,081.13 / $1,543.40 / $2,110.19
| Professional | | $1,081.13 | $1,543.40 | $2,110.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.14 / $1,518.59 / $1,952.89
| Professional | | $213.14 | $1,518.59 | $1,952.89 |