- 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
- $847.80 / $847.80 / $847.80
| Professional | | $847.80 | $847.80 | $847.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.31 / $1,134.75 / $1,361.70
| Professional | | $895.31 | $1,134.75 | $1,361.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.28 / $1,331.09 / $1,571.51
| Professional | | $1,216.28 | $1,331.09 | $1,571.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.58 / $1,089.35 / $1,270.92
| Professional | | $998.58 | $1,089.35 | $1,270.92 |
- 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
- $894.54 / $1,134.75 / $1,395.12
| Professional | | $894.54 | $1,134.75 | $1,395.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.77 / $2,575.00 / $6,124.00
| Professional | | $999.77 | $2,575.00 | $6,124.00 |