- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $6,084.00 / $7,424.00
| Facility | | $2,528.00 | $6,084.00 | $7,424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.99 / $1,015.65 / $1,015.65
| Professional | | $970.99 | $1,015.65 | $1,015.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.04 / $1,161.35 / $1,161.35
| Professional | | $935.04 | $1,161.35 | $1,161.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.15 / $1,521.43 / $1,795.29
| Professional | | $1,354.15 | $1,521.43 | $1,795.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.00 / $1,114.91 / $1,300.73
| Professional | | $1,022.00 | $1,114.91 | $1,300.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.32 / $1,224.10 / $1,507.61
| Professional | | $1,152.32 | $1,224.10 | $1,507.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $984.02 / $1,557.03
| Professional | | $29.27 | $984.02 | $1,557.03 |