- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.71 / $835.71 / $835.71
| Professional | | $835.71 | $835.71 | $835.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.20 / $985.05 / $1,182.06
| Professional | | $772.20 | $985.05 | $1,182.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.01 / $1,224.66 / $3,857.00
| Professional | | $1,090.01 | $1,224.66 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.84 / $945.65 / $1,103.26
| Professional | | $866.84 | $945.65 | $1,103.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.80 / $985.05 / $1,224.21
| Professional | | $803.80 | $985.05 | $1,224.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.10 / $3,619.79 / $9,324.00
| Professional | | $713.10 | $3,619.79 | $9,324.00 |