- 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
- $590.54 / $590.54 / $590.54
| Professional | | $590.54 | $590.54 | $590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.29 / $772.75 / $927.30
| Professional | | $596.29 | $772.75 | $927.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.56 / $878.31 / $1,036.96
| Professional | | $802.56 | $878.31 | $1,036.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.02 / $741.84 / $865.48
| Professional | | $680.02 | $741.84 | $865.48 |
- 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
- $603.42 / $772.75 / $966.75
| Professional | | $603.42 | $772.75 | $966.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.87 / $2,575.00 / $6,124.00
| Professional | | $611.87 | $2,575.00 | $6,124.00 |