- 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
- $929.25 / $971.88 / $971.88
| Professional | | $929.25 | $971.88 | $971.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.70 / $1,111.55 / $1,111.55
| Professional | | $894.70 | $1,111.55 | $1,111.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.02 / $1,453.87 / $1,715.57
| Professional | | $1,294.02 | $1,453.87 | $1,715.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.16 / $1,067.08 / $1,244.94
| Professional | | $978.16 | $1,067.08 | $1,244.94 |
- 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
- $907.02 / $1,111.55 / $1,442.48
| Professional | | $907.02 | $1,111.55 | $1,442.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $920.50 / $1,447.40
| Professional | | $29.27 | $920.50 | $1,447.40 |