- 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
- $1,406.43 / $1,406.43 / $1,406.43
| Professional | | $1,406.43 | $1,406.43 | $1,406.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.85 / $1,698.96 / $2,038.76
| Professional | | $1,319.85 | $1,698.96 | $2,038.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.74 / $2,033.30 / $8,430.00
| Professional | | $1,809.74 | $2,033.30 | $8,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.09 / $1,631.00 / $1,902.84
| Professional | | $1,495.09 | $1,631.00 | $1,902.84 |
- 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
- $1,383.64 / $1,698.96 / $2,190.60
| Professional | | $1,383.64 | $1,698.96 | $2,190.60 |
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 |