- 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
- $669.27 / $669.27 / $669.27
| Professional | | $669.27 | $669.27 | $669.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.11 / $899.64 / $1,079.57
| Professional | | $695.11 | $899.64 | $1,079.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.21 / $1,023.49 / $1,265.29
| Professional | | $935.21 | $1,023.49 | $1,265.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.68 / $863.65 / $1,007.59
| Professional | | $791.68 | $863.65 | $1,007.59 |
- 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
- $707.74 / $899.64 / $1,131.51
| Professional | | $707.74 | $899.64 | $1,131.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.95 / $2,575.00 / $6,124.00
| Professional | | $705.95 | $2,575.00 | $6,124.00 |