- 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
- $778.73 / $778.73 / $778.73
| Professional | | $778.73 | $778.73 | $778.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.42 / $920.56 / $1,104.68
| Professional | | $711.42 | $920.56 | $1,104.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.40 / $1,124.38 / $1,327.46
| Professional | | $1,027.40 | $1,124.38 | $1,327.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.10 / $883.74 / $1,031.03
| Professional | | $810.10 | $883.74 | $1,031.03 |
- 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
- $751.18 / $920.56 / $1,159.50
| Professional | | $751.18 | $920.56 | $1,159.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.16 / $2,582.96 / $6,124.00
| Professional | | $878.16 | $2,582.96 | $6,124.00 |