- 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
- $1,226.92 / $1,226.92 / $1,226.92
| Professional | | $1,226.92 | $1,226.92 | $1,226.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.66 / $1,382.71 / $1,659.26
| Professional | | $1,194.66 | $1,382.71 | $1,659.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.73 / $1,597.52 / $1,935.26
| Professional | | $1,459.73 | $1,597.52 | $1,935.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.79 / $1,327.40 / $1,548.64
| Professional | | $1,216.79 | $1,327.40 | $1,548.64 |
- 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
- $1,012.64 / $1,346.06 / $1,756.68
| Professional | | $1,012.64 | $1,346.06 | $1,756.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.00 / $2,582.96 / $6,124.00
| Professional | | $1,005.00 | $2,582.96 | $6,124.00 |