- 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
- $491.91 / $491.91 / $491.91
| Professional | | $491.91 | $491.91 | $491.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.94 / $758.83 / $910.59
| Professional | | $578.94 | $758.83 | $910.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.79 / $873.87 / $5,851.00
| Professional | | $777.79 | $873.87 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.77 / $728.47 / $849.88
| Professional | | $667.77 | $728.47 | $849.88 |
- 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
- $582.21 / $758.83 / $937.47
| Professional | | $582.21 | $758.83 | $937.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.94 / $2,575.00 / $6,124.00
| Professional | | $585.94 | $2,575.00 | $6,124.00 |