- 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
- $406.36 / $639.85 / $1,095.68
| Professional | | $406.36 | $639.85 | $1,095.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.39 / $779.61 / $845.25
| Professional | | $563.39 | $779.61 | $845.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.93 / $890.34 / $1,056.93
| Professional | | $752.93 | $890.34 | $1,056.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.41 / $743.82 / $946.68
| Professional | | $530.41 | $743.82 | $946.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.72 / $845.25 / $1,021.13
| Professional | | $689.72 | $845.25 | $1,021.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.92 / $2,575.00 / $6,124.00
| Professional | | $613.92 | $2,575.00 | $6,124.00 |