- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $5,484.00 / $6,718.00
| Facility | | $1,924.00 | $5,484.00 | $6,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.85 / $657.34 / $985.85
| Professional | | $596.85 | $657.34 | $985.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.62 / $819.10 / $1,657.01
| Professional | | $651.62 | $819.10 | $1,657.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.93 / $981.88 / $1,129.16
| Professional | | $873.93 | $981.88 | $1,129.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.60 / $786.34 / $917.39
| Professional | | $694.60 | $786.34 | $917.39 |
- 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
- $646.34 / $819.10 / $1,111.13
| Professional | | $646.34 | $819.10 | $1,111.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.42 / $800.96 / $899.33
| Professional | | $112.42 | $800.96 | $899.33 |