- 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
- $415.75 / $553.73 / $791.88
| Professional | | $415.75 | $553.73 | $791.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.01 / $843.91 / $1,012.70
| Professional | | $655.01 | $843.91 | $1,012.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.41 / $650.59 / $818.86
| Professional | | $558.41 | $650.59 | $818.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.50 / $742.64 / $843.91
| Professional | | $550.50 | $742.64 | $843.91 |
- 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
- $671.56 / $843.91 / $1,094.01
| Professional | | $671.56 | $843.91 | $1,094.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.23 / $2,500.00 / $6,063.00
| Professional | | $574.23 | $2,500.00 | $6,063.00 |