- 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
- $647.33 / $660.26 / $660.26
| Professional | | $647.33 | $660.26 | $660.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.36 / $771.29 / $925.55
| Professional | | $594.36 | $771.29 | $925.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.08 / $986.55 / $8,430.00
| Professional | | $878.08 | $986.55 | $8,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.73 / $740.44 / $863.84
| Professional | | $678.73 | $740.44 | $863.84 |
- 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
- $629.37 / $794.95 / $961.46
| Professional | | $629.37 | $794.95 | $961.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.75 / $2,582.96 / $6,124.00
| Professional | | $740.75 | $2,582.96 | $6,124.00 |