- 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
- $694.81 / $694.81 / $694.81
| Professional | | $694.81 | $694.81 | $694.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.16 / $892.58 / $1,071.08
| Professional | | $689.16 | $892.58 | $1,071.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.40 / $983.02 / $1,130.47
| Professional | | $928.40 | $983.02 | $1,130.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.47 / $856.87 / $999.68
| Professional | | $785.47 | $856.87 | $999.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.60 / $892.58 / $1,121.91
| Professional | | $701.60 | $892.58 | $1,121.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.16 / $2,575.00 / $6,124.00
| Professional | | $722.16 | $2,575.00 | $6,124.00 |