- 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
- $597.13 / $708.85 / $708.85
| Professional | | $597.13 | $708.85 | $708.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.08 / $911.81 / $911.81
| Professional | | $769.08 | $911.81 | $911.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.95 / $1,251.78 / $4,334.00
| Professional | | $1,087.95 | $1,251.78 | $4,334.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.40 / $875.34 / $1,021.23
| Professional | | $802.40 | $875.34 | $1,021.23 |
- 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
- $744.04 / $911.81 / $1,257.65
| Professional | | $744.04 | $911.81 | $1,257.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.18 / $2,582.96 / $6,124.00
| Professional | | $942.18 | $2,582.96 | $6,124.00 |