- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $2,747.00 / $6,084.00
| Facility | | $2,528.00 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.11 / $678.11 / $678.11
| Professional | | $678.11 | $678.11 | $678.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.83 / $847.68 / $1,017.21
| Professional | | $654.83 | $847.68 | $1,017.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.85 / $966.19 / $1,140.70
| Professional | | $882.85 | $966.19 | $1,140.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.95 / $813.77 / $949.40
| Professional | | $745.95 | $813.77 | $949.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.41 / $766.64 / $1,071.10
| Professional | | $667.41 | $766.64 | $1,071.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $667.35 / $908.52
| Professional | | $29.27 | $667.35 | $908.52 |