- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.55 / $2,747.00 / $5,484.00
| Facility | | $1,635.55 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.01 / $990.85 / $1,764.00
| Professional | | $779.01 | $990.85 | $1,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.45 / $1,137.09 / $1,364.52
| Professional | | $982.45 | $1,137.09 | $1,364.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.18 / $1,333.83 / $13,672.00
| Professional | | $1,187.18 | $1,333.83 | $13,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.65 / $1,091.61 / $1,273.55
| Professional | | $1,000.65 | $1,091.61 | $1,273.55 |
- 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
- $844.17 / $1,106.39 / $1,460.52
| Professional | | $844.17 | $1,106.39 | $1,460.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.28 / $3,802.95 / $9,325.00
| Professional | | $824.28 | $3,802.95 | $9,325.00 |