- 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
- $272.17 / $404.73 / $815.95
| Professional | | $272.17 | $404.73 | $815.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.59 / $608.10 / $729.72
| Professional | | $474.59 | $608.10 | $729.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.75 / $580.49 / $752.94
| Professional | | $482.75 | $580.49 | $752.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.97 / $515.66 / $608.10
| Professional | | $351.97 | $515.66 | $608.10 |
- 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
- $481.35 / $608.10 / $788.10
| Professional | | $481.35 | $608.10 | $788.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.36 / $2,500.00 / $6,063.00
| Professional | | $417.36 | $2,500.00 | $6,063.00 |