- 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
- $568.26 / $568.26 / $568.26
| Professional | | $568.26 | $568.26 | $568.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.25 / $773.39 / $928.07
| Professional | | $596.25 | $773.39 | $928.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.28 / $879.10 / $1,037.89
| Professional | | $803.28 | $879.10 | $1,037.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.58 / $742.45 / $866.19
| Professional | | $680.58 | $742.45 | $866.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.42 / $773.39 / $966.68
| Professional | | $603.42 | $773.39 | $966.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.80 / $2,582.96 / $6,124.00
| Professional | | $713.80 | $2,582.96 | $6,124.00 |