- 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
- $923.80 / $923.80 / $923.80
| Professional | | $923.80 | $923.80 | $923.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.87 / $1,216.91 / $1,460.30
| Professional | | $950.87 | $1,216.91 | $1,460.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.06 / $1,567.25 / $1,850.32
| Professional | | $1,432.06 | $1,567.25 | $1,850.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.88 / $1,168.24 / $1,362.94
| Professional | | $1,070.88 | $1,168.24 | $1,362.94 |
- 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
- $993.00 / $1,216.91 / $1,581.54
| Professional | | $993.00 | $1,216.91 | $1,581.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.00 / $2,575.00 / $6,124.00
| Professional | | $1,005.00 | $2,575.00 | $6,124.00 |