- 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
- $468.54 / $468.54 / $468.54
| Professional | | $468.54 | $468.54 | $468.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.97 / $699.73 / $839.67
| Professional | | $539.97 | $699.73 | $839.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.38 / $816.11 / $5,851.00
| Professional | | $726.38 | $816.11 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.76 / $671.74 / $783.69
| Professional | | $615.76 | $671.74 | $783.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.61 / $699.73 / $878.69
| Professional | | $549.61 | $699.73 | $878.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.74 / $2,582.96 / $6,124.00
| Professional | | $665.74 | $2,582.96 | $6,124.00 |