- 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
- $626.85 / $626.85 / $626.85
| Professional | | $626.85 | $626.85 | $626.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.84 / $892.18 / $1,070.60
| Professional | | $688.84 | $892.18 | $1,070.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.98 / $1,015.57 / $1,199.00
| Professional | | $927.98 | $1,015.57 | $1,199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.11 / $856.49 / $999.24
| Professional | | $785.11 | $856.49 | $999.24 |
- 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
- $701.24 / $892.18 / $1,121.36
| Professional | | $701.24 | $892.18 | $1,121.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.69 / $2,575.00 / $6,124.00
| Professional | | $706.69 | $2,575.00 | $6,124.00 |