- 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
- $434.38 / $434.38 / $434.38
| Professional | | $434.38 | $434.38 | $434.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.59 / $887.91 / $1,065.50
| Professional | | $687.59 | $887.91 | $1,065.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.38 / $793.63 / $5,851.00
| Professional | | $706.38 | $793.63 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.36 / $852.40 / $994.46
| Professional | | $781.36 | $852.40 | $994.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.49 / $887.91 / $1,136.58
| Professional | | $506.49 | $887.91 | $1,136.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.87 / $2,582.96 / $6,124.00
| Professional | | $633.87 | $2,582.96 | $6,124.00 |