- 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
- $641.87 / $641.87 / $641.87
| Professional | | $641.87 | $641.87 | $641.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.06 / $864.38 / $1,037.25
| Professional | | $667.06 | $864.38 | $1,037.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.76 / $983.60 / $1,161.26
| Professional | | $898.76 | $983.60 | $1,161.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.65 / $829.80 / $968.10
| Professional | | $760.65 | $829.80 | $968.10 |
- 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
- $690.67 / $864.38 / $1,084.97
| Professional | | $690.67 | $864.38 | $1,084.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.43 / $2,575.00 / $6,124.00
| Professional | | $725.43 | $2,575.00 | $6,124.00 |