- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.00 / $2,898.00 / $3,444.00
| Facility | | $988.00 | $2,898.00 | $3,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.52 / $571.52 / $571.52
| Professional | | $571.52 | $571.52 | $571.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.17 / $782.01 / $875.85
| Professional | | $688.17 | $782.01 | $875.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,106.00 / $1,106.00
| Facility | | $1,106.00 | $1,106.00 | $1,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.39 / $769.00 / $1,016.23
| Professional | | $476.39 | $769.00 | $1,016.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.71 / $893.37 / $1,051.02
| Professional | | $735.71 | $893.37 | $1,051.02 |