- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.43 / $2,747.00 / $6,084.00
| Facility | | $1,861.43 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.34 / $559.34 / $559.34
| Professional | | $559.34 | $559.34 | $559.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.42 / $637.96 / $765.56
| Professional | | $483.42 | $637.96 | $765.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.70 / $814.22 / $3,857.00
| Professional | | $724.70 | $814.22 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.41 / $612.44 / $714.52
| Professional | | $561.41 | $612.44 | $714.52 |
- 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
- $520.58 / $637.96 / $835.50
| Professional | | $520.58 | $637.96 | $835.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.20 / $3,619.79 / $9,324.00
| Professional | | $562.20 | $3,619.79 | $9,324.00 |