- 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
- $126.99 / $456.11 / $796.18
| Professional | | $126.99 | $456.11 | $796.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.26 / $621.80 / $746.18
| Professional | | $477.26 | $621.80 | $746.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.01 / $699.33 / $825.64
| Professional | | $639.01 | $699.33 | $825.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.20 / $596.94 / $696.43
| Professional | | $547.20 | $596.94 | $696.43 |
- 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
- $474.37 / $621.80 / $765.24
| Professional | | $474.37 | $621.80 | $765.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.00 / $2,500.00 / $6,063.00
| Professional | | $508.00 | $2,500.00 | $6,063.00 |