- 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
- $505.93 / $505.93 / $505.93
| Professional | | $505.93 | $505.93 | $505.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.45 / $649.90 / $779.88
| Professional | | $500.45 | $649.90 | $779.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.34 / $735.81 / $868.71
| Professional | | $672.34 | $735.81 | $868.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.91 / $623.90 / $727.89
| Professional | | $571.91 | $623.90 | $727.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.20 / $649.90 / $806.16
| Professional | | $525.20 | $649.90 | $806.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.59 / $2,582.96 / $6,124.00
| Professional | | $588.59 | $2,582.96 | $6,124.00 |