- 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
- $511.52 / $511.52 / $511.52
| Professional | | $511.52 | $511.52 | $511.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.09 / $705.20 / $846.24
| Professional | | $542.09 | $705.20 | $846.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.01 / $795.62 / $939.33
| Professional | | $727.01 | $795.62 | $939.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.58 / $676.99 / $789.82
| Professional | | $620.58 | $676.99 | $789.82 |
- 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
- $542.23 / $705.20 / $872.40
| Professional | | $542.23 | $705.20 | $872.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.29 / $2,650.00 / $6,124.00
| Professional | | $742.29 | $2,650.00 | $6,124.00 |