- 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
- $473.37 / $588.40 / $718.44
| Professional | | $473.37 | $588.40 | $718.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.53 / $476.14 / $665.18
| Professional | | $388.53 | $476.14 | $665.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.28 / $893.17 / $1,123.18
| Professional | | $776.28 | $893.17 | $1,123.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.91 / $403.76 / $476.14
| Professional | | $275.91 | $403.76 | $476.14 |
- 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
- $388.53 / $493.19 / $1,156.89
| Professional | | $388.53 | $493.19 | $1,156.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.15 / $2,500.00 / $6,063.00
| Professional | | $353.15 | $2,500.00 | $6,063.00 |