- 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
- $575.22 / $575.22 / $575.22
| Professional | | $575.22 | $575.22 | $575.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.05 / $774.50 / $929.40
| Professional | | $599.05 | $774.50 | $929.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.39 / $917.24 / $3,857.00
| Professional | | $816.39 | $917.24 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.56 / $743.52 / $867.44
| Professional | | $681.56 | $743.52 | $867.44 |
- 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
- $631.99 / $774.50 / $986.78
| Professional | | $631.99 | $774.50 | $986.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.05 / $2,575.00 / $6,124.00
| Professional | | $672.05 | $2,575.00 | $6,124.00 |