- 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
- $831.83 / $831.83 / $831.83
| Professional | | $831.83 | $831.83 | $831.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.08 / $1,114.70 / $1,337.64
| Professional | | $879.08 | $1,114.70 | $1,337.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.17 / $1,341.69 / $5,851.00
| Professional | | $1,194.17 | $1,341.69 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.94 / $1,070.10 / $1,248.46
| Professional | | $980.94 | $1,070.10 | $1,248.46 |
- 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
- $843.88 / $1,114.70 / $1,368.57
| Professional | | $843.88 | $1,114.70 | $1,368.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.92 / $2,575.00 / $6,124.00
| Professional | | $987.92 | $2,575.00 | $6,124.00 |