- 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
- $612.79 / $612.79 / $612.79
| Professional | | $612.79 | $612.79 | $612.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.10 / $806.40 / $967.68
| Professional | | $621.10 | $806.40 | $967.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.44 / $914.29 / $1,079.44
| Professional | | $835.44 | $914.29 | $1,079.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.63 / $774.14 / $903.17
| Professional | | $709.63 | $774.14 | $903.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.89 / $806.40 / $1,007.09
| Professional | | $630.89 | $806.40 | $1,007.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.68 / $3,619.79 / $9,324.00
| Professional | | $663.68 | $3,619.79 | $9,324.00 |