- 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
- $309.73 / $441.01 / $568.83
| Professional | | $309.73 | $441.01 | $568.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.77 / $626.80 / $752.18
| Professional | | $486.77 | $626.80 | $752.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.97 / $635.09 / $768.27
| Professional | | $539.97 | $635.09 | $768.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.42 / $539.21 / $626.80
| Professional | | $395.42 | $539.21 | $626.80 |
- 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
- $501.40 / $626.80 / $815.60
| Professional | | $501.40 | $626.80 | $815.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.32 / $2,500.00 / $6,063.00
| Professional | | $447.32 | $2,500.00 | $6,063.00 |