- 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
- $539.67 / $596.80 / $927.12
| Professional | | $539.67 | $596.80 | $927.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,267.63 / $3,267.63 / $3,267.63
| Facility | | $3,267.63 | $3,267.63 | $3,267.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.07 / $745.79 / $1,498.06
| Professional | | $601.07 | $745.79 | $1,498.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.34 / $891.34 / $1,073.33
| Professional | | $793.34 | $891.34 | $1,073.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.29 / $715.96 / $835.28
| Professional | | $656.29 | $715.96 | $835.28 |
- 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
- $572.63 / $745.79 / $1,007.87
| Professional | | $572.63 | $745.79 | $1,007.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.14 / $9,435.00 / $12,953.00
| Professional | | $542.14 | $9,435.00 | $12,953.00 |