- 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
- $591.83 / $822.97 / $822.97
| Professional | | $591.83 | $822.97 | $822.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.62 / $889.06 / $889.06
| Professional | | $702.62 | $889.06 | $889.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.30 / $1,099.15 / $4,334.00
| Professional | | $955.30 | $1,099.15 | $4,334.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.38 / $853.50 / $995.75
| Professional | | $782.38 | $853.50 | $995.75 |
- 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
- $725.48 / $889.06 / $1,122.23
| Professional | | $725.48 | $889.06 | $1,122.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.89 / $2,582.96 / $6,124.00
| Professional | | $852.89 | $2,582.96 | $6,124.00 |