- 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
- $800.08 / $860.25 / $1,264.15
| Professional | | $800.08 | $860.25 | $1,264.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.50 / $1,014.30 / $1,023.20
| Professional | | $810.50 | $1,014.30 | $1,023.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.90 / $1,374.83 / $8,902.00
| Professional | | $1,194.90 | $1,374.83 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.58 / $973.73 / $1,136.02
| Professional | | $892.58 | $973.73 | $1,136.02 |
- 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
- $827.67 / $1,014.30 / $1,310.42
| Professional | | $827.67 | $1,014.30 | $1,310.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.26 / $2,582.96 / $6,124.00
| Professional | | $724.26 | $2,582.96 | $6,124.00 |