- 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
- $715.84 / $715.84 / $715.84
| Professional | | $715.84 | $715.84 | $715.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.67 / $913.50 / $1,096.20
| Professional | | $705.67 | $913.50 | $1,096.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.29 / $1,039.99 / $1,227.83
| Professional | | $950.29 | $1,039.99 | $1,227.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.88 / $876.96 / $1,023.12
| Professional | | $803.88 | $876.96 | $1,023.12 |
- 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
- $719.06 / $913.50 / $1,149.63
| Professional | | $719.06 | $913.50 | $1,149.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.87 / $2,575.00 / $6,124.00
| Professional | | $747.87 | $2,575.00 | $6,124.00 |