- 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
- $721.46 / $751.38 / $1,108.95
| Professional | | $721.46 | $751.38 | $1,108.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.27 / $889.23 / $893.23
| Professional | | $708.27 | $889.23 | $893.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.98 / $1,159.46 / $1,368.16
| Professional | | $1,031.98 | $1,159.46 | $1,368.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.52 / $853.66 / $995.93
| Professional | | $782.52 | $853.66 | $995.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.61 / $889.23 / $1,146.48
| Professional | | $725.61 | $889.23 | $1,146.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.29 / $2,582.96 / $6,124.00
| Professional | | $638.29 | $2,582.96 | $6,124.00 |