- 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
- $694.83 / $694.83 / $694.83
| Professional | | $694.83 | $694.83 | $694.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.01 / $890.29 / $1,068.34
| Professional | | $687.01 | $890.29 | $1,068.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.32 / $1,011.58 / $1,194.29
| Professional | | $924.32 | $1,011.58 | $1,194.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.45 / $854.68 / $997.12
| Professional | | $783.45 | $854.68 | $997.12 |
- 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
- $709.57 / $890.29 / $1,109.67
| Professional | | $709.57 | $890.29 | $1,109.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.60 / $2,582.96 / $6,124.00
| Professional | | $833.60 | $2,582.96 | $6,124.00 |