- 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
- $609.46 / $609.46 / $609.46
| Professional | | $609.46 | $609.46 | $609.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.51 / $780.38 / $936.45
| Professional | | $602.51 | $780.38 | $936.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.08 / $912.40 / $5,851.00
| Professional | | $812.08 | $912.40 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.73 / $749.16 / $874.02
| Professional | | $686.73 | $749.16 | $874.02 |
- 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
- $610.28 / $780.38 / $977.43
| Professional | | $610.28 | $780.38 | $977.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.72 / $2,575.00 / $6,124.00
| Professional | | $639.72 | $2,575.00 | $6,124.00 |