- 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
- $762.03 / $762.03 / $1,191.02
| Professional | | $762.03 | $762.03 | $1,191.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.09 / $941.63 / $1,129.95
| Professional | | $728.09 | $941.63 | $1,129.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.10 / $1,102.29 / $5,851.00
| Professional | | $981.10 | $1,102.29 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.63 / $903.96 / $1,054.61
| Professional | | $828.63 | $903.96 | $1,054.61 |
- 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
- $744.30 / $941.63 / $1,188.41
| Professional | | $744.30 | $941.63 | $1,188.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.55 / $2,575.00 / $6,124.00
| Professional | | $745.55 | $2,575.00 | $6,124.00 |