- 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
- $279.05 / $426.89 / $532.90
| Professional | | $279.05 | $426.89 | $532.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.27 / $630.14 / $756.17
| Professional | | $492.27 | $630.14 | $756.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.26 / $592.74 / $784.21
| Professional | | $501.26 | $592.74 | $784.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.06 / $534.36 / $630.14
| Professional | | $357.06 | $534.36 | $630.14 |
- 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
- $502.19 / $630.14 / $822.96
| Professional | | $502.19 | $630.14 | $822.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.73 / $2,500.00 / $6,063.00
| Professional | | $438.73 | $2,500.00 | $6,063.00 |