- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,456.00
| Facility | | $1,324.03 | $2,747.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.31 / $1,001.31 / $1,052.57
| Professional | | $1,001.31 | $1,001.31 | $1,052.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.11 / $1,151.41 / $1,204.28
| Professional | | $1,035.11 | $1,151.41 | $1,204.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.65 / $1,493.90 / $1,762.80
| Professional | | $1,329.65 | $1,493.90 | $1,762.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.24 / $1,105.35 / $1,289.58
| Professional | | $1,013.24 | $1,105.35 | $1,289.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.55 / $1,151.41 / $1,487.33
| Professional | | $939.55 | $1,151.41 | $1,487.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.16 / $2,582.96 / $6,124.00
| Professional | | $855.16 | $2,582.96 | $6,124.00 |