- 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
- $717.25 / $717.25 / $717.25
| Professional | | $717.25 | $717.25 | $717.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.03 / $965.90 / $1,159.08
| Professional | | $745.03 | $965.90 | $1,159.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.75 / $1,210.88 / $5,851.00
| Professional | | $1,077.75 | $1,210.88 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.99 / $927.26 / $1,081.81
| Professional | | $849.99 | $927.26 | $1,081.81 |
- 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
- $788.17 / $965.90 / $1,212.61
| Professional | | $788.17 | $965.90 | $1,212.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.30 / $2,582.96 / $6,124.00
| Professional | | $919.30 | $2,582.96 | $6,124.00 |