- 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
- $841.33 / $841.33 / $841.33
| Professional | | $841.33 | $841.33 | $841.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.86 / $1,121.98 / $1,346.37
| Professional | | $884.86 | $1,121.98 | $1,346.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.56 / $1,314.97 / $1,552.49
| Professional | | $1,201.56 | $1,314.97 | $1,552.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.34 / $1,077.09 / $1,256.60
| Professional | | $987.34 | $1,077.09 | $1,256.60 |
- 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
- $896.30 / $1,121.98 / $1,377.81
| Professional | | $896.30 | $1,121.98 | $1,377.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.09 / $2,575.00 / $6,124.00
| Professional | | $998.09 | $2,575.00 | $6,124.00 |