- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $3,570.48 / $4,456.00
| Facility | | $1,758.00 | $3,570.48 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.49 / $444.62 / $924.20
| Professional | | $317.49 | $444.62 | $924.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.33 / $708.41 / $850.10
| Professional | | $545.33 | $708.41 | $850.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.14 / $710.85 / $864.95
| Professional | | $610.14 | $710.85 | $864.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.47 / $602.01 / $708.41
| Professional | | $441.47 | $602.01 | $708.41 |
- 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
- $539.50 / $699.45 / $890.52
| Professional | | $539.50 | $699.45 | $890.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.71 / $2,500.00 / $6,063.00
| Professional | | $463.71 | $2,500.00 | $6,063.00 |