- 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
- $589.77 / $589.77 / $589.77
| Professional | | $589.77 | $589.77 | $589.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.90 / $835.76 / $1,002.92
| Professional | | $599.90 | $835.76 | $1,002.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.55 / $962.58 / $1,136.43
| Professional | | $879.55 | $962.58 | $1,136.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.47 / $802.33 / $936.05
| Professional | | $735.47 | $802.33 | $936.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.12 / $835.76 / $1,024.14
| Professional | | $636.12 | $835.76 | $1,024.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.20 / $2,582.96 / $6,124.00
| Professional | | $693.20 | $2,582.96 | $6,124.00 |