- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,817.00
| Facility | | $1,324.03 | $2,747.00 | $4,817.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.00 / $390.00 / $390.00
| Professional | | $390.00 | $390.00 | $390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.66 / $438.06 / $525.67
| Professional | | $340.66 | $438.06 | $525.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.62 / $344.84 / $518.24
| Professional | | $291.62 | $344.84 | $518.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.11 / $371.48 / $438.06
| Professional | | $210.11 | $371.48 | $438.06 |
- 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
- $349.08 / $438.06 / $577.70
| Professional | | $349.08 | $438.06 | $577.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.20 / $2,500.00 / $6,063.00
| Professional | | $315.20 | $2,500.00 | $6,063.00 |