- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.55 / $2,747.00 / $5,484.00
| Facility | | $1,635.55 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.62 / $464.41 / $591.41
| Professional | | $329.62 | $464.41 | $591.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.17 / $674.75 / $809.70
| Professional | | $527.17 | $674.75 | $809.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.46 / $691.13 / $840.49
| Professional | | $584.46 | $691.13 | $840.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.85 / $572.19 / $674.75
| Professional | | $411.85 | $572.19 | $674.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,106.00 / $1,106.00
| Facility | | $1,106.00 | $1,106.00 | $1,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.48 / $674.75 / $887.60
| Professional | | $545.48 | $674.75 | $887.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.90 / $488.21 / $735.18
| Professional | | $91.90 | $488.21 | $735.18 |