- 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
- $710.44 / $710.44 / $710.44
| Professional | | $710.44 | $710.44 | $710.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.74 / $989.80 / $1,187.76
| Professional | | $762.74 | $989.80 | $1,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.89 / $1,138.05 / $1,343.60
| Professional | | $1,039.89 | $1,138.05 | $1,343.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.02 / $950.21 / $1,108.58
| Professional | | $871.02 | $950.21 | $1,108.58 |
- 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
- $790.16 / $989.80 / $1,261.67
| Professional | | $790.16 | $989.80 | $1,261.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.18 / $2,582.96 / $6,124.00
| Professional | | $927.18 | $2,582.96 | $6,124.00 |