- 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
- $255.89 / $366.26 / $801.79
| Professional | | $255.89 | $366.26 | $801.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.02 / $639.73 / $767.67
| Professional | | $522.02 | $639.73 | $767.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.35 / $683.94 / $916.57
| Professional | | $552.35 | $683.94 | $916.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.36 / $511.78 / $639.73
| Professional | | $368.36 | $511.78 | $639.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.02 / $639.73 / $1,286.90
| Professional | | $522.02 | $639.73 | $1,286.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.78 / $4,326.00 / $6,487.00
| Professional | | $352.78 | $4,326.00 | $6,487.00 |