- 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
- $376.25 / $514.87 / $709.98
| Professional | | $376.25 | $514.87 | $709.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.25 / $765.19 / $918.23
| Professional | | $594.25 | $765.19 | $918.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.46 / $808.20 / $942.87
| Professional | | $683.46 | $808.20 | $942.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.20 / $668.46 / $765.19
| Professional | | $490.20 | $668.46 | $765.19 |
- 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
- $604.76 / $765.19 / $987.21
| Professional | | $604.76 | $765.19 | $987.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.42 / $2,500.00 / $6,063.00
| Professional | | $519.42 | $2,500.00 | $6,063.00 |