- 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
- $428.06 / $577.20 / $824.62
| Professional | | $428.06 | $577.20 | $824.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.86 / $872.89 / $1,047.47
| Professional | | $683.86 | $872.89 | $1,047.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.53 / $938.02 / $1,089.09
| Professional | | $797.53 | $938.02 | $1,089.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.73 / $768.14 / $872.89
| Professional | | $572.73 | $768.14 | $872.89 |
- 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
- $685.15 / $872.89 / $1,115.30
| Professional | | $685.15 | $872.89 | $1,115.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.23 / $2,500.00 / $6,063.00
| Professional | | $608.23 | $2,500.00 | $6,063.00 |