- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.88 / $2,747.00 / $3,883.00
| Facility | | $1,157.88 | $2,747.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.96 / $1,637.61 / $5,909.96
| Professional | | $1,096.96 | $1,637.61 | $5,909.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.10 / $1,306.00 / $1,567.20
| Professional | | $1,022.10 | $1,306.00 | $1,567.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.49 / $1,565.63 / $5,851.00
| Professional | | $1,393.49 | $1,565.63 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.28 / $1,253.76 / $1,462.72
| Professional | | $1,149.28 | $1,253.76 | $1,462.72 |
- 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
- $1,064.67 / $1,306.00 / $1,690.08
| Professional | | $1,064.67 | $1,306.00 | $1,690.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.30 / $2,000.00 / $5,304.00
| Professional | | $945.30 | $2,000.00 | $5,304.00 |