- 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
- $274.25 / $335.83 / $1,162.09
| Professional | | $274.25 | $335.83 | $1,162.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.96 / $1,281.75 / $1,751.98
| Professional | | $341.96 | $1,281.75 | $1,751.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.77 / $510.00 / $1,823.19
| Professional | | $442.77 | $510.00 | $1,823.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.96 / $1,541.74 / $1,751.98
| Professional | | $355.96 | $1,541.74 | $1,751.98 |
- 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
- $1,336.14 / $1,751.98 / $1,890.17
| Professional | | $1,336.14 | $1,751.98 | $1,890.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.88 / $2,500.00 / $6,063.00
| Professional | | $374.88 | $2,500.00 | $6,063.00 |