- 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
- $656.73 / $656.73 / $656.73
| Professional | | $656.73 | $656.73 | $656.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.00 / $777.11 / $932.54
| Professional | | $607.00 | $777.11 | $932.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.47 / $913.24 / $1,078.18
| Professional | | $834.47 | $913.24 | $1,078.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.86 / $746.03 / $870.37
| Professional | | $683.86 | $746.03 | $870.37 |
- 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
- $634.12 / $777.11 / $1,024.25
| Professional | | $634.12 | $777.11 | $1,024.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.81 / $2,582.96 / $6,124.00
| Professional | | $656.81 | $2,582.96 | $6,124.00 |