- 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
- $927.97 / $927.97 / $927.97
| Professional | | $927.97 | $927.97 | $927.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.69 / $1,168.33 / $1,402.01
| Professional | | $904.69 | $1,168.33 | $1,402.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.32 / $1,336.61 / $1,578.02
| Professional | | $1,221.32 | $1,336.61 | $1,578.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.14 / $1,121.59 / $1,308.54
| Professional | | $1,028.14 | $1,121.59 | $1,308.54 |
- 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
- $928.38 / $1,168.33 / $1,479.66
| Professional | | $928.38 | $1,168.33 | $1,479.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.61 / $5,990.97 / $9,416.00
| Professional | | $834.61 | $5,990.97 | $9,416.00 |