- 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
- $594.32 / $655.20 / $655.20
| Professional | | $594.32 | $655.20 | $655.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.02 / $849.49 / $849.49
| Professional | | $696.02 | $849.49 | $849.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.87 / $1,045.74 / $6,874.20
| Professional | | $908.87 | $1,045.74 | $6,874.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.55 / $815.51 / $951.43
| Professional | | $747.55 | $815.51 | $951.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.18 / $849.49 / $1,089.21
| Professional | | $693.18 | $849.49 | $1,089.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.99 / $2,582.96 / $6,124.00
| Professional | | $832.99 | $2,582.96 | $6,124.00 |