- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,818.38 / $3,890.45
| Facility | | $741.31 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,122.02
| Professional | | $645.65 | $758.58 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $1,023.29
| Professional | | $724.44 | $870.96 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $7,762.47
| Professional | | $977.24 | $1,148.15 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $1,000.00
| Professional | | $707.95 | $794.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,202.26
| Professional | | $588.84 | $870.96 | $1,202.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,089.30 / $5,370.32
| Professional | | $870.96 | $2,089.30 | $5,370.32 |