- 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
- $591.45 / $591.45 / $1,002.85
| Professional | | $591.45 | $591.45 | $1,002.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.89 / $746.89 / $805.13
| Professional | | $746.89 | $746.89 | $805.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.39 / $1,009.50 / $13,672.00
| Professional | | $877.39 | $1,009.50 | $13,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.51 / $772.92 / $901.74
| Professional | | $708.51 | $772.92 | $901.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.98 / $805.13 / $1,033.33
| Professional | | $656.98 | $805.13 | $1,033.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.74 / $2,582.96 / $6,124.00
| Professional | | $773.74 | $2,582.96 | $6,124.00 |