- 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
- $1,327.98 / $1,327.98 / $1,327.98
| Professional | | $1,327.98 | $1,327.98 | $1,327.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.77 / $1,638.89 / $1,966.67
| Professional | | $1,274.77 | $1,638.89 | $1,966.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.37 / $1,891.52 / $2,233.16
| Professional | | $1,728.37 | $1,891.52 | $2,233.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.22 / $1,573.33 / $1,835.55
| Professional | | $1,442.22 | $1,573.33 | $1,835.55 |
- 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
- $1,337.33 / $1,638.89 / $2,116.42
| Professional | | $1,337.33 | $1,638.89 | $2,116.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.00 / $2,575.00 / $6,124.00
| Professional | | $1,161.00 | $2,575.00 | $6,124.00 |