- 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
- $587.80 / $587.80 / $587.80
| Professional | | $587.80 | $587.80 | $587.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.01 / $1,344.30 / $1,613.16
| Professional | | $1,040.01 | $1,344.30 | $1,613.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.06 / $1,002.52 / $1,183.59
| Professional | | $916.06 | $1,002.52 | $1,183.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.98 / $1,290.53 / $1,505.62
| Professional | | $1,182.98 | $1,290.53 | $1,505.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.38 / $1,344.30 / $1,712.07
| Professional | | $682.38 | $1,344.30 | $1,712.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.17 / $2,575.00 / $6,124.00
| Professional | | $959.17 | $2,575.00 | $6,124.00 |